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THE 


SURGERY  OF  THE  CHEST. 


THE 

SURGERY 
OF  THE  CHEST. 


BY 

STEPHEN     PAGET,    M.A.    Oxon.,    F.R.C.S., 

SURGEON  TO  THE  WEST  LONDON  HOSPITAL,  AND 
TO  THE  METROPOLITAN  HOSPITAL. 


ILLUSTRATED. 


NEW  YORK:  E.   B.  TREAT,  5  COOPER  UNION. 

JOHN  WRIGHT  &  CO.,  BRISTOL,  ENGLAND. 

J.   HOOD  COMPANY,  MONTREAL. 

1897. 


MAGISTRIS    MEIS    OMNIBUS 

PRIMO    PR^SERTIM    OMNIUM    ET    SUM  MO 

PATRI     DILECTISSIMO 

IMO    DE    PECTORE 

REFERO    GRATIAS    LIBELLUM     DEDICO. 


PREFACE. 

From  time  to  time  I  have  published  notes  on 
cases  illustrating  the  Surgery  of  the  Chest,  and 
in  this  way  I  was  led  to  study  the  accumulated 
records  of  it.  During  the  last  five  and  twenty 
years,  thanks  to  Lister,  it  has  advanced  with  won- 
derful rapidity :  and  there  has  been  an  equally 
rapid  increase  of  the  literature  relating  to  it,  both 
in  this  country  and  abroad. 

Concerning  one  most  important  part  of  my 
subject,  the  Diseases  of  the  Lungs  and  Pleura;,  we 
shall  before  long  have  a  work  written  in  part  by 
Mr.  Godlee,  the  pioneer  of  English  surgeons  in  this 
great  field  of  practice.  But  hitherto  no  attempt 
has  been  made  in  England  to  put  together  a  book 
on  the  whole  subject  of  the  Surgery  of  the  Chest, 
both  in  injury  and  in  disease. 

Now  is  the  time  when  such  a  book  can  hardly 
fail  to  be  useful  :  first,  because  there  is  a  vast  store 
of  good  material  to  be  worked  into  it  ;  next, 
because  there  are  signs  that  we  have  reached  a 
stage,  in  this  portion  of  our  art,  beyond  which,  on 
our  present  lines,  we  cannot  advance  much  further. 

However  this  may  be,  I  have  tried  to  state  the 


viii  PREFACE. 

case  for  Surgery,  as  it  now  stands,  clearly  and 
fairly  :  and  to  present,  from  a  wealth  of  scattered 
writings,  those  rules  which  are  most  likely  to  help 
the  surgeon  in  the  difficulties  of  practice.  Reading 
the  literature  of  this  great  field  of  Surgery,  I  have 
often  found  myself  wandering  off  the  main  road 
down  pleasant  unfrequented  paths  :  for  I  have  tried 
to  make  a  collection  of  such  facts  and  experiences 
as  lie  outside  the  usual  course  of  our  work. 

The  original  drawings  in  the  book  w&vq  done 
by  my  wife.  Dr.  Hunter  has  been  so  good  as  to 
review  what  I  have  written,  and  to  keep  it  free 
from  mistakes  in  those  parts  of  it  that  are  medical 
rather  than  surgical.  M.  Reclus  has  let  me  add  to 
it  a  translation  of  his  address  at  the  French  Sur- 
gical Congress  last  year. 

Prof.  Polaillon's  very  valuable  work  ("Affections 
Chirurgicales  du  Tronc,"  Paris,  1896),  contains 
many  cases  which  I  would  have  noted  :  but  it  was 
not  published  till  this  book  had  passed  out  of  my 
hands. 

57,  WiMPOLE  Street,  W., 
June,  iSg6. 


CONTENTS. 


PART    /.—INJURIES    OF    THE    CHEST. 

PAGl!. 

— Surgical  Landmarks.     Congenital  Malformations  i 

— Concussion  and  Contusion  of  the  Chest         -  8 
— Fractures    and     Dislocations    of     Ribs,     Costal 

Cartilages,  and  Sternu.m    -            -            -            -  14 

4. — Simple  Fractures  with  Internal  Injuries        -  35 

_«). — Surgical  Emphysema    -             -             -             -             -  55 

6. — Pneumothorax           -----  64 

7. — Hernia  of  the  Lung    -             -             -             -             -  78 
—Wounds  of   Intercostal   and   Internal   MA.^LMARY 

Arteries.     H.emothorax              -             -             -  87 

—Wounds  of  the  Lung  -----  106 

—Wounds  of  the  Heart       -             -             .             .  121 
—  Wounds    of    the    Diaphragm.      Diaphragmatic 

Hernia               ----..  1^0 

PART    //.—DISEASES    OF    THE    CHEST. 

12. — Caries  and  Necrosis    of   Ribs  and    Sternum.      In- 
flammation of  Anterior  Mediastinum  -  154 
13. — Tumours  of  the  Ribs  and  Sternum-             -             -   167 
14. — Pleural  Effusions,  other  than  Empyema        -  184 
15. —  Empyema  -------  204 

16. — Operation  for  "Empyema     .  -  -  -         230 

17. — Difficulties  that  may  arise  after  Operation      -  246 
18. — Chronic  Empyema  with  Fistula.     Estlander's  and 

Schede's  Operations        -  -  .  .  270 

19. — Abscess  of  Lung.     Bronchiectasis    -  -  -  2S6 

H 


X  CONTENTS. 

PACK. 

20. — Gangrene  of  Lung  -  -  .  .         302 

21.— Tubercular  Phthisis    -----  314 
22. — Inflammation  of  the  Bronchial  Glands  and  the 

Posterior  Mediastinum  -  .  -  -         335 

23. — Foreign  Bodies  in  the  Air-Passages  -  -  356 

24. — The  "Surgery  of  the  Heart"    -  -  -         371 

25. — Pericardial  Effusions  .  _  -  -  384 

26. — Intra-Thoractc    Tumours.      Hydatid    Disease. 

Actinomycosis       -----         3g8 
27. — Subphrenic   Abscess.      Hydatid   of   the   Liver  in- 
vading THE  Chest     -  -  -  -  -  422 

Appendix  A. — M.  Reclus'  Address  at  the  French  Surgical 
Congress  of  1S95. 

Appendix  B. — On  Bulau's  Treatment  of  Empyema  by  Con- 
tinuous Syphon-Drainage. 


LIST     OF     PLATES. 


I. — Usual  Form  of  Displacement  of  Sternum      -             -  26 
II. — Wound  of  Intercostal  Artery  in  the  Operation  for 

Empyema           -             ...             -  89 
III.-  Multiple  Tuberculous  Osteo  Myelitis  of  the  Ribs    -  15S 
IV. — Caries  and  Necrosis  of  Sternum  -             -             -  165 
V. — {A .)  Extreme  Thickening  of  Pleura,  with  small  cir- 
cumscribed cavity       -              -              -              -  222 
(B.)  Extreme  Thickening  of  Pleura,  with  small  cir- 
cumscribed empyema       -             -             -  222 
VI.  —  (A.)  Ulceration  of  Pleura       .             -             -             -  251 
{B.)  Tuberculous  Disease  of  Pleura        -             -  251 
VII. — Transverse  Section  of  Chest  from   Fatal  Case  of 

Chronic  Empyema              .             _             .             _  280 

VIII. — Advanced  Bronchiectasis  of  Lower  Part  of  Lung  294 

IX.  —  Gangrene  of  Lung            -             -             -             -  310 

X. — Bronchial  and  Mediastinal  Glands    -             -             -  337 

XI. — Lungs  and  Air  Passages,  with  a  foreign  body  in 

right  bronchus  -----  368 

XII.  —  (A.)   Diagram  of  Pyo-Pneumothorax            -             -  424 

(5.)  Diagram  of  Subphrenic  Abscess   -             -  424 


ADDENDA    ET    CORRIGENDA. 


1.  Fractures  of  First  Rib  and  of  Sternum  (Chap.  III). — I  have 
omitted  a  reference  to  Mr.  Arbuthnot  Lane's  valuable  papers  in 
the  "Transactions  of  the  Pathological  Society,"  1883,  84,  and 
85.  See  also  Dr.  Rolleston's  paper,  in  the  "Transactions"  for 
1S91. 

2.  Wounds  of  the  Heart  (Chap.  X). — The  reference  to  Cap- 
pelen's  operation  will  be  found  at  the  end  of  the  chapter  on  the 
"  Surgery  of  the  Heart." 

3.  Diaphragmatic  Hernia  (Chap.  XI). — There  is  a  valuable 
paper  by  Dr.  Jaffe,  on  Congenital  Diaphragmatic  Hernia,  with 
a  collection  of  twelve  cases,  in  all  of  which  a  sac  was  present, 
in  the  "  Pathological  Society's  Transactions,"  for  1894. 

4.  CEdema  of  Lun^  after  Aspiration  of  Pleural  Effusion  (Chap. 
XIV). — This  subject  was  recently  brought  before  the  Clinical 
Society,  by  Dr.  West  (April  icth,  1896) ;  Dr.  Hale  White  also 
reported  a  case  at  the  same  meeting. 

5.  Extensive  Resection  of  Ribs  for  Empyema  (Chap.  XVIII). — Dr. 
F.  W.  Murray  has  lately  recorded  two  cases  of  sudden  cedema 
of  the  opposite  lung  after  this  operation,  one  on  the  fourth  day, 
the  other,  a  fatal  attack,  on  the  tenth  day  ("Annals  of  Surgery," 
May,  1806)'. 


SURGERY  OF  THE  CHEST. 


Part     I.— INJURIES     OF     THE     CHEST. 


CHAPTER    I. 

THE  LANDMARKS  OF  THE  CHEST.     CONGENITAL 
MALFORMATIONS. 

npHE  'surgical  landmarks'  of  the  chest,i  so  far  as  we 
-*-  are  here  concerned,  are  not  numerous.  In  front, 
we  may  take  a  Hne  one  finger's  breadth  from  the  edge  of 
the  sternum,  to  mark  the  course  of  the  internal  mammary 
artery.  The  vein  lies  a  little  nearer  the  sternum  than 
the  artery.  A  wound  half  an  inch  from  the  edge  of  the 
sternum  may  divide  the  artery,-  and  its  blood  will  pour 
either  into  the  pleura,  or  the  mediastinum,  or  both. 
Behind  the  manubrium  sterni  lie  the  left  innominate  vein, 

'"Landmarks  Medical  and  Surgical,"  Holden,  second  edition, 
1877:  True,  "  Essai  sur  la  Chirurgie  du  Poumon,"  1885.  The 
course  of  the  internal  mammary  artery  is  illustrated  in  Sir  Astley 
Cooper's  "  Anatomy  of  the  Breast."  See  also  Vosz,  "  Die  Ver- 
letzungen  der  Arteria  Mammaria  Interna,"  Inaug.  Diss.  Dorpat, 
1884.  He  gives  a  number  of  exact  measurements:  practically, 
any  deep  wound  about  half-an-inch  from  the  sternum  may 
divide  the  artery. 

-  "  Toute  blessure  situee  le  long  du  sternum  a  un  centimetre 
au  moins  de  cet  os,  de  la  premiere  cote  a  la  septieme,  lorsqu'elle 
a  une  profondeur  suffisante,  peut  faire  soupfonner  la  lesion  de 
I'artere  "  (Toxirdes). 

T 


2    .  SURGERY    OF    THE    CHEST. 

and,  beneath  the  vein,  the  great  branches  of  the  aortic 
arch.  The  top  of  the  arch,  and,  behind  it,  the  bifurca- 
tion of  the  trachea,  he  behind  the  junction  of  the 
manubrium  with  the  body  of  the  sternum. 

The  pleurae  slope  toward  each  other  behind  the  ster- 
num, and  may  even  be  in  contact  about  the  level  of  the 
middle  of  the  sternum ;  but  the  anterior  mediastinum 
slants  a  little  to  the  left,  so  that  a  puncture  through  the 
middle  of  the  sternum  would  be  more  likely  to  wound 
the  right  pleura  than  the  left.  The  exposed  area  of  the 
heart  (area  of  cardiac  dulness)  is  about  covered  by  a 
circle  two  inches  across,  having  its  centre  midway 
between  the  nipple  and  the  juncture  between  the  ster- 
num and  the  ensiform  cartilage ;  and  a  stethoscope  put 
over  the  third  intercostal  space,  just  at  the  edge  of  the 
sternum,  may  cover  some  part  of  all  the  valves  of  the 
heart.  At  the  sides  of  the  chest,  the  edge  of  the  pleura 
follows  a  line,  slightly  curved  downward,  drawn  from  the 
juncture  between  the  sternum  and  the  ensiform  cartilage, 
to  the  last  rib. 

The  lungs  rise  an  inch  or  an  inch  and  a  half  above 
the  level  of  the  first  ribs ;  and  there  is  a  very  rare  con- 
genital malformation,  first  noted  by  Cruveilhiori  during 
dissection  of  a  foetus,  where  one  or  both  apices  rise  high 
into  the  neck,  lying  alongside  the  cervical  spine.  From 
a  surgical  point  of  view,  True  divides  the  lungs  into 
three  zones  :  upper,  middle,  and  lower.  The  lower  zone 
occupies  the  space  between  the  ribs  and  the  diaphragm, 
and  is  moulded  to  the  surface  of  the  diaphragm.     The 


'  For  references,  see  Riedinger.  Of  this  nature  was  a  case  shown 
some  years  ago  at  one  of  the  London  Medical  Societies — a  little 
girl  whose  lungs  rose  so  high  into  the  neck  as  to  form  well-marked 
swellings,  soft,  crepitant,  resonant,  moving  with  the  movements 
of  respiration. 


SURGICAL     LANDMARKS.  3 

middle  zone  is  most  easily  accessible,  and  even  that  part 
of  it  which  lies  beneath  the  scapula  is  not  out  of  the 
surgeon's  reach.  The  upper  zone  presents  serious  diffi- 
culties, yet  it  may  be  reached  either  in  front,  between  the 
internal  mammary  and  the  axillary  vessels  (the  internal 
mammary  artery  is  a  finger's  breadth  from  the  edge  of 
the  sternum,  the  axillary  vein  is  3-^-  inches  from  the 
middle  line  of  the  sternum  at  the  level  of  the  first  space, 
and  4f  inches  from  it  at  the  level  of  the  second  space), 
or  from  the  axilla.  The  chest  wall  is  thin  here,  and  any 
space  from  the  second  to  the  fifth  may  safely  be  punctured, 
if  the  arm  be  held  away  from  the  side,  and  if  care  be 
taken  of  the  branches  of  the  axillary  artery  (the  long 
thoracic  artery  lies  two  fingers'  breadth  from  the  edge  of 
the  pectoralis  major).  True  adds  the  following  rules  for 
safe  exploratory  puncture  of  the  lungs :  in  puncturing 
the  upper  zone  in  front,  through  the  first  or  second  space, 
direct  your  needle  upward,  backward,  and  outward ;  in 
puncturing  it  from  the  axilla,  go  upward,  backward,  and 
inward.  To  reach  the  apex  of  the  lung  from  behind, 
just  grazing  the  upper  border  of  the  scapula,  outside  the 
suprascapular  notch,  and  entering  the  chest  through  the 
second  space,  is  anatomically  possible,  but  he  would 
rather  not  attempt  it.  Over  the  greater  part  of  the  lung, 
one  may  safely  thrust  a  needle  i  inch  backward,  or  i^ 
inch  backward  and  outward.  The  neighbourhood  of  the 
root  of  the  lung  must  be  carefully  avoided.  The  heart 
must  be  avoided  by  never  puncturing  within  the  left 
nipple-line,  or  within  a  breadth  of  three  fingers  on  the 
right  side  of  the  sternum.  A  deep  inspiration,  separating 
the  ribs,  is  favourable  to  puncture. 

The  surgical  landmarks  of  the  posterior  mediastinum 
are  noted  in  the  chapter  on  inflammation  of  that 
region. 


4"  SURGERY    OF    THE    CHEST. 

Congenital  Malformations. 

Among  congenital  malformations  of  the  chest,i  we  have 
to  note  the  presence  of  gaps  or  clefts  in  the  sternum, 
and  deficiencies  in  the  chest  wall  from  arrested  growth  of 
the  ribs.  In  a  case  lately  under  the  care  of  one  of  my 
colleagues  at  the  Metropolitan  Hospital,  there  was  on 
the  left  side  of  the  chest  a  gap  of  four  or  five  inches  in 
diameter,  with  entire  absence  of  bone.  These  gaps,  like 
some  other  congenital  defects,  are  usually  on  the  left  side 
of  the  body.  Two  instances  of  this  deformity  are 
recorded  by  Dr.  Abercrombie  in  the  Transactions  of 
the  Clinical  Society,  1893.  It  was  at  one  time  believed 
that  there  is  such  a  congenital  malformation  as  a  heart 
without  a  pericardium,  but  the  dissections  that  estab- 
lished this  belief  were  really  cases  of  densely  adherent 
pericardium. 

There  is  a  trivial  deformity  of  the  chest,  which  may  be 
worth  noting  here,  a  protrusion  of  the  lower  costal  car- 
tilages on  the  left  side,  below  the  level  of  the  breast,  in 
women.  I  have  seen  three  instances  of  it.  Two  of  the 
patients  came  up  from  the  country  in  great  alarm,  and  all 
three  believed  they  had  disease  of  the  breast,  or  some 
internal  growth  pushing  the  ribs  forward.  I  have  never 
seen  this  prominence  of  the  ribs  on  the  right  side,  or  on 
both  sides.  It  seems  therefore  to  be  due  not  to  tight 
lacing,  but  to  some  want  of  symmetry  of  growth. 

Cervical  ribs,  though  they  can  hardly  be  called  deform- 
ities of  the  chest,  may  be  mentioned  here.     The  best 


'  Pierre  Marie  has  just  published  a  valuable  Clinical  Lecture 
"  Deformations  Thoraciques  dans  quelques  Affections  Medi- 
cales,"  which  includes  an  account  of  certain  general  congenital 
malformations  of  the  chest  which  may  accompany  arrest  of 
development  of  the  heart  or  the  central  nervous  system, 
"  Le9ons  de  Clinique  Medicale,"  Paris,  1896. 


SURGICAL     LANDMARKS.  5 

clinical  account  of  them  that  I  know  has  lately  been 
given  by  Tilmann.^  They  are  more  often  found  post 
mortem  than  noted  during  life.  Thus,  Griiber  collected 
notes  of  45  post  mortem  examinations,  but  only  2 
clinical  observations;  and  Pilling  (1894)  recorded  92 
instances,  all  post  mortem.  They  are  more  often  double 
than  single,  but  are  seldom  quite  symmetrical.  The 
cervical  rib  may  not  extend  beyond  the  transverse  process 
of  the  vertebra  ;  or  it  may  extend  beyond  it,  but  not  join 
the  first  rib,  or  may  join  the  bony  part  of  it ;  or  it  may 
join  the  cartilage  of  the  first  rib  ;  or  it  may  have  a  car- 
tilage of  its  own,  fused  with  the  cartilage  of  the  first  rib. 
Of  26  cases  during  life,  collected  by  Tillmann,  13  had 
their  attention  called  to  the  presence  of  the  rib  during  the 
course  of  a  long  illness:  13  suffered  pain  from  it.  Ten 
gained  relief  from  treatment  without  operation  ;  three 
underwent  operation  successfully.  All  the  patients  were 
above  20  years  old  :  he  therefore  supposes  that  a  cervical 
rib,  though  present  at  birth,  does  not  cause  pressure-symp- 
toms till  some  wasting  illness,  or  the  advance  of  age,  has 
thinned  the  patient.  In  some  cases,  the  brachial  plexus 
is  compressed,  so  that  the  patient  has  pain,  weakness, 
chilliness  of  the  arm,  prickling  sensations  in  it,  loss  of 
the  sense  of  touch,  even  wasting  of  the  limb.  In  others 
it  is  the  subclavian  artery  that  bears  the  brunt  of  the 
pressure :  the  radial  pulse  is  weak,  or  wholly  absent,  the 
arm  becomes  cold,  mottled,  and  dusky;  gangrene  has 
occurred,  and  even  subclavian  aneurysm.  It  is  to  be  noted 
that  these  troubles  of  circulation  tend  toward  recovery  by 
the  establishment  of  a  collateral  blood-supply.  Fischer  is 
of  opinion  that  even  if  an  aneurysm  occur,  it  tends  toward 


'  Die  Klinische  Bedeutung  der  Halsrippen.    "  Deutsche  Ztschr. 
f.  Chir.,"  1895,  xli,  parts  4  and  5. 


6  SURGERY    OF    THE    CHEST. 

a  natural  cure,  by  extension  of  coagulation,  beginning  in 
the  hand,  up  the  brachial  artery  until  it  reaches  the  sac 
of  the  aneurysm.  He  would  therefore  not  interfere 
unless  there  be  signs  of  pressure  on  the  brachial 
plexus 

Should  operation  be  necessary,  the  skin  incision  must 
be  very  carefully  placed.  If  any  muscles  are  attached  to 
the  rib,  they  must  be  loosed  from  it  by  subperiosteal 
resection  (not  that  there  is  any  other  reason  for  saving 
the  periosteum),  and  the  surgeon  must  remember  how 
near  he  is  to  the  thin,  loose  pleura.  In  one  case  at  least 
the  operation  has  been  followed  by  pneumothorax. 
Tilmann's  own  case  is  worth  study. 

A  woman,  aged  44,  had  for  seven  years  been  conscious  of 
pain  in  the  left  side  of  her  neck,  and  had  noted  a  hard  nodule 
there,  which  seemed  to  be  slowly  growing  larger,  and  was 
troublesome  when  she  turned  her  head  or  lay  down  in  bed. 
Latterly  she  had  observed  that  the  muscles  of  her  thumb  were 
wasted,  and  that  her  arm  was  weak  and  chilly,  with  shooting 
pains  in  it.  About  an  inch  above  the  middle  of  the  clavicle 
was  a  bony  growth,  which  felt  about  the  size  of  a  hazel-nut. 
It  seemed  to  extend  upward  and  backward  toward  the  trans- 
verse process  of  the  last  cervical  vertebra,  and  forward  and 
downward  beneath  the  clavicle,  pushing  the  subclavian  artery 
forward  and  upward.  There  were  marked  wasting  and  loss 
of  power  of  the  arm  and  hand,  with  some  loss  of  faradic 
excitability.  Pressure  on  the  growth  caused  pain  down  the 
arm.  The  colour  and  warmth  of  the  arm,  and  the  radial  pulse, 
were  not  altered.  A  free  incision  was  made,  exposing  the 
growth.  A  few  fibres  of  the  scalenus  anticus  were  found 
attached  to  it.  The  scalenus  medius  had  its  proper  attach- 
ment, but  was  somewhat  thinned  out  over  the  growth.  The 
brachial  plexus  crossed  over  it,  but  was  easily  drawn  out  of 
the  way  toward  the  middle  line.  Some  fibres  of  the  scalenus 
medius  were  divided.  The  growth  was  cleared  by  subperios- 
teal resection,  divided  in  front  with  a  chain-saw,  and  removed 
piecemeal  with  the  cutting-forceps.  A  very  small  opening  was 
made  into  the  pleura,  but  no  harm  came  of  it.  The  pains  in 
the  arm  slowly  disappeared  after  the  operation  ;  but  the  arm 
was  still  wasted  four  months  after  it. 


SURGICAL     LANDMARKS.  7 

Deformities  of  the  chest  following  curvature  of  the 
spine  do  not  concern  us  here ;  nor  are  we  likely  to  adopt 
a  suggestion  lately  made  by  a  French  surgeon,  that 
one  should  correct  the  evil  consequences  of  lateral 
curvature  by  resection  of  ribs. 


CHAPTER     II. 

CONCUSSION  AND  CONTUSION  OF  THE  CHEST. 

General  injuries  of  the  chest,  without  fracture  of  the 
chest  wall  or  penetrating  wound  of  the  soft  parts,  are 
seldom  dangerous  to  life.  The  vital  organs  are  not  ex- 
posed, like  the  abdominal  viscera,  to  mortal  injury  by 
any  slight  contusion  ;  nor  are  they,  like  the  brain,  so 
delicate  that  even  a  slight  concussion  may  be 
disastrous.  Thus  we  are  tempted  to  make  light  of  a 
general  injury  of  the  chest,  unaccompanied  by  fracture, 
or  by  a  serious  wound  of  the  soft  tissues.  But,  apart 
from  the  fact  that  very  grave  and  even  fatal  results  may 
follow  a  blow  or  a  bruise  over  the  chest  which  seemed  in 
itself  insignificant,  the  general  injuries  of  the  chest  are 
sometimes  attended  by  changes  so  unexpected  and  so 
obscure,  that  they  need  careful  consideration.  As  with 
the  abdomen,  so  with  the  chest,  the  pressure  of  a  carriage- 
wheel,  or  of  the  buffers  of  a  railway-truck,  may,  even 
without  fracture  or  external  wound,  have  strange 
consequences,  beyond  the  reach  of  diagnosis  or  even  of 
guess-work.  A  treatise  on  'run-over'  cases^  would  form 
a  valuable  addition  to  the  literature  of  surgery,  on  the 
lines  of  Kaufman  n's  recent  work,  'A  Manual  of 
Accidental  Injuries.' 

Experience  of  cases  of  simple  contusion  of  the  chest, 
without  internal   injury,    teaches   us,   first,   that   children 

■  Several  valuable  cases  are  given  in  Mr.  Pitts'  "  Lectures  on 
the  Surgery  of  the  Air  Passages  and  Thorax  in  Children," 
"Lancet,"  October,   1893. 


CONCUSSION  AND  CONTUSION  OF  THE  CHEST,     g 

sometimes  escape  almost  unhurt  from  accidents  which 
would  have  given  small  chance  of  escape  to  adults :  next, 
that  the  shock  of  these  accidents  is  much  severer  in 
some  cases  than  in  others.  There  are  several  reasons  for 
the  frequent  escape  of  small  children  when  run  over.  They 
more  readily  roll  or  are  pushed  from  beneath  the  wheel ; 
their  ribs  are  more  elastic  than  those  of  an  adult ;  the 
rounded  shape  of  their  chests  offers  greater  resistance  to 
pressure:  finally, ^  since  the  wheel  first  ascends  the  chest 
slowly  and  heavily,  and  then  rolls  down  more  rapidly  and 
less  heavily  from  the  other  side,  its  passage  would  be 
quicker  and  lighter  over  the  small  round  chest  of  the 
child. 

The  shock  from  such  an  injury  varies  widely,  but,  as  a 
rule,  it  is  severe.  In  children,  there  is  sometimes  to  be 
noted  an  extraordinary  swiftness  of  respiration.  This 
may  fairly  be  considered  as  part  of  the  shock  ;  but  it  lasts 
in  some  cases  long  after  the  usual  signs  of  shock  have 
passed  away.  There  may  be  no  dyspnoea,  no  duskiness 
of  face,  nothing  to  suggest  injury  of  the  lung :  only  a 
rapidity  of  sixty  or  even  seventy  respirations  a  minute. 
I  do  not  think  this  symptom  is  so  marked  in  adults,  and  I 
believe  it  is  not,  by  itself,  any  sign  of  serious  injury. 

There  need  be  no  general  extensive  contusion  of 
the  chest  to  cause  severe  and  even  fatal  shock.  It 
may  follow  a  blow  from  a  spent  bullet  or  fragment  of 
shell  in  a  battle.  It  has  been  said-  that  such  injuries 
'are  at  least  as  dangerous  as  penetrating  wounds  of  the 
chest.'  Even  should  this  statement  be  somewhat  exag- 
gerated, there  are  plenty  of  cases  to  show  that  a  slight 
blow,  limited  to  one  part  of  the  chest,  may  be  followed 


'Bijhr.      "  Ueber     den     Mechanismus     der    Rippenbriiche." 
'Deutsch.  Ztschr.  f.  Klin.  Chir."  1894,  39>  251. 
""Pirogoff.  "Grundziiged.  Kriegschirurgie."  1864. 


lo  SURGERY    OF    THE    CHEST. 

by  shock  out  of  all  proportion  to  the  injury,  or  even  by 
death.  There  is  no  violent  or  frightful  crushing  of  the 
chest  to  account  for  it.  To  these  strange  cases  Ried- 
inger'  gives  the  name  'Concussion  of  the  Chest' — 
co7Ji7iiotio  thoracica.  For  example,  in  the  daily  papers  of 
Jan.  28th,  of  the  present  year,  there  is  an  account  of  the 
sudden  death  of  a  woman,  aged  45,  at  whom  a  boy,  aged 
15,  had  thrown  a  stone.  'It  struck  her  in  the  region  of 
the  heart,  and  she  at  once  fell  back,  exclaiming.  Oh  my 
breast.  Oh  my  breast.'  She  became  unconscious,  and 
died  before  help  could  be  obtained."  Riedinger  gives 
the  following  cases,  (i,)  A  man  was  dragging  a  heavy 
load  behind  him  :  the  rope  broke,  he  fell  forward  on  his 
chest,  and  died  at  once.  Post  mortem,  there  was  slight 
contusion  of  the  chest  wall,  but  no  injury  of  heart  or 
lungs  (2,)  A  man,  convalescent  after  diabetes,  was 
struck  on  the  chest  with  a  stone  thrown  at  him,  and  fell 
dead.  (3,)  An  old  man  was  suddenly  struck  on  the 
upper  part  of  the  chest :  he  staggered  back,  fell,  and 
died  at  once.  Post  mortejn,  there  was  no  injury  of  heart 
or  lungs ;  old  valvular  lesions ;  cut  head  and  slight 
extravasations  in  the  pia  mater.  But  such  cases  as  these 
are  evidently  examples  of  heart-failure,  from  weakness  or 
valvular  disease  of  the  heart. 

Riedinger  sought  by  experiment  to  ascertain  the  exact 
character  of  the  syncope  which  attends  concussion  of 


' "  Verletzungen  und  Chirurgische  Krankheiten  des  Thorax  und 
seines  Inhaltes."  "  Deutsche  Chirurgie,"  Lieferung  42.  Stuttgart 
1888. 

^  Dr.  Austin,  of  Lingfield,  Surrey,  has  kindly  sent  me  notes  of 
the  post  moytcm  examination.  The  right  auricle  was  distended 
with  blood ;  the  left  auricle,  and  both  ventricles,  were  empty. 
There  was  great  hypertrophy  of  the  ventricles,  the  left  ventricle 
being  fully  an  inch  thick ;  the  tricuspid  and  mitral  valves  were 
incompetent,  and  there  were  vegetations  on  the  mitral  valve. 


CONCUSSION  AND  CONTUSION  OF  THE  CHEST,    ii 

the  chest.  SHght  blows  over  the  region  of  the  heart 
had  no  marked  effect  on  the  blood-pressure ;  it  sank  a 
little  after  each  of  them,  but  soon  rose  again  to  normal. 
A  single  heavy  blow  made  it  descend  low  at  once,  then 
it  rose  quickly ;  a  second  made  it  sink  even  lower  than 
the  first,  but  it  rose  again ;  after  a  third,  it  went  lower 
than  ever,  and  remained  low  for  some  time.  Repeated 
heavy  blows  could  not  bring  it  below  a  certain  level, 
and  only  caused  irregular  fluctuations.  These  fallings 
of  the  blood-pressure  were  not  due  to  any  direct  com- 
pression of  the  heart  itself;  care  was  taken  to  avoid 
this.  They  were  less  marked,  if  the  depressor  nerves, 
and  the  vagi,  or  the  cervical  sympathetic,  were  previously 
divided.  Concussion  of  the  chest  is  a  complex  process. 
The  fall  of  the  blood-pressure  after  a  blow  is  probably 
du<;  to  direct  stimulation  of  the  vagi :  that  it  still 
occurs,  though  the  vagi  have  been  divided,  must  be 
due  to  direct  compression  of  the  heart :  that  it  lasts  for 
some  time  even  after  the  blows  have  ceased,  is  probably 
due  to  the  action  of  the  depressor  nerves  and  of  the 
sympathetic,  whereby  more  blood  flows  into  the  splanchnic 
vessels. 

If  we  are  called  to  deal  with  a  case  of  contusion 
of  the  chest  with  severe  shock,  but  without  evident 
fracture,  wound,  or  internal  injury,  we  must  not  wait  to 
make  a  prolonged  examination,  but  must  proceed  at  once 
to  treat  the  shock,  much  as  we  treat  a  case  of  syncope  from 
chloroform,  laying  the  patient  flat  wath  his  head  lower 
than  his  body,  using  warmth,  stimulants,  hypodermics  of 
ether  or  strychnine,  or  both,  and  very  hot  cloths,  or  the 
faradic  current,  over  the  heart.  It  may  even  be  necessary 
to  do  artificial  respiration. 

The  external  injuries  in  simple  contusion  of  the  chest, 
and  simple  superficial  wounds  of  the  soft  parts,  as  a  rule 


12  SURGERY    OF    THE    CHEST. 

heal  rapidly;  the  intercostal  and  internal  mammary  ves- 
sels, being  uninjured,  are  left  free  to  carry  on  the  work  of 
repair.  The  superficial  veins  are  hardly  large  enough  to 
cause  any  large  subcutaneous  haemorrhage.  Riedinger, 
however,  notes  a  case  of  very  extensive  extravasation  under 
the  skin  of  the  back  after  contusion  of  this  region  ;  and 
blows  over  the  breast  may  have  a  like  result.  The  worst 
case  of  this  kind  I  have  ever  seen  was  that  of  a  young 
soldier  whose  horse  in  a  fit  of  rage  had  seized  him  over 
the  left  breast.  The  whole  breast,  and  the  tissues  round 
it,  were  distended  and  uplifted  off  the  pectoral  muscle  by 
a  profuse  extravasation,  and  were  for  many  days  so  tense 
that  the  skin  seemed  on  the  very  point  of  breaking  down  ; 
but  slowly  the  whole  of  the  huge  clot  was  absorbed,  with- 
out suppuration.  It  is  of  the  utmost  importance  that  one 
should  thoroughly  cleanse  and  disinfect  any  lacerated 
wound  of  the  soft  parts.  For  if  suppuration  take  place 
among  or  between  the  intercostal  muscles,  it  may  burrow 
quietly  far  and  wide,  prevented  by  the  deep  fascia  and 
the  pleura  from  making  its  way  into  the  pleural  cavity, 
and  by  the  ribs  and  muscles  from  making  its  way 
outward  under  the  skin. 

The  internal  injuries  that  may  be  caused  by  simple 
general  contusion  of  the  chest,  even  without  fracture, 
range  from  the  slightest  rift  in  the  pleura  to  the  most 
extensive  laceration  of  the  lung.  These  injuries  are 
more  likely  to  happen  if  the  accident  comes  very  swiftly 
and  unexpectedly,  at  a  moment  when  the  lungs  are  fully 
expanded,  and  the  glottis  closed.'  Emphysema,  pneumo- 
thorax, pleurisy  with  effusion,  hernia  of  the  lung,  haemo- 
thorax,  laceration  of  the  heart  or  lung,  rupture  of  the 
diaphragm — all  these  have  been  noted  after  simple  con- 

'Gosselin:  Dechirures  du  Poumon.      "Mem.  Soc.  Chir."  i.  201. 


CONCUSSION  AND  CONTUSION  OF  THE  CHEST.    13 

tusion  without  fracture  ;  nor,  if  one  or  other  of  them 
occur  in  a  case  where  the  ribs  or  the  sternum  are  frac- 
tured, does  it  follow  that  the  fracture  had  anything  to  do 
with  it. 

We  are  bound  therefore  not  to  think  lightly  of 
contusion  of  the  chest  merely  because  there  is  no  fracture 
or  external  wound.  I  can  find  no  evidence  that  contusion 
alone  can  bring  about  rupture  of  an  intercostal  or  internal 
mammary  artery;  but,  however  this  may  be,  the  list  of 
possible  lesions  is  long  enough  to  warn  us  to  be  watchful. 
Absolute  rest  in  bed,  immediate  treatment  of  the  shock, 
careful  observation  of  the  patient  till  one  is  sure  that  no 
internal  harm  has  been  done — all  these  precautions  are 
necessary  in  every  case  of  severe  contusion. 


14 


CHAPTER    III. 

FRACTURES   AND   DISLOCATIONS   OF  THE  RIBS, 
COSTAL  CARTILAGES,  AND  STERNUM. 

It  is  impossible  to  make  a  satisfactory  division  of 
the  various  injuries  of  the  chest,  or,  having  made  it, 
to  keep  to  it.  Perhaps  the  best  that  can  be  done  will  be  to 
devote  this  chapter  to  the  simple  fractures  and  dis- 
locations of  the  ribs,  costal  cartilages,  and  sternum,  as 
they  are  in  themselves,  giving  separate  chapters  to  some  of 
the  grave  dangers  and  troubles  that  may  be  caused  by 
them,  or  may  accompany  or  follow  them.  A  case  of 
simple  fracture  of  the  ribs,  with  extensive  emphysema  or 
profuse  haemoptysis,  presents  itself  to  us,  not  as  a  case  of 
fractured  ribs,  but  rather  as  emphysema  or- as  wound  of 
the  lung.  It  is  absurd  to  consider  the  emphysema  or 
hsemoptysis  as  less  important  than  the  fracture  ;  it  is  just 
the  wound  of  the  pleura,  or  lung,  that  we  have  most  to 
consider. 

Simple  Fractures  of  the  Ribs. 

There  is  so  much  valuable  work  on  this  subject  in  the 
writings  of  Malgaigne,  Gurlt,  Riedinger,  Hamilton, 
Poland,  and  many  others,  that  the  experience  of  one 
surgeon  is  of  little  value.  And  the  subject  itself  is  so 
wide,  that  I  do  not  attempt,  even  from  the  work  of 
others,  to  treat  it  at  length. 

The  most  frequent  seat  of  fracture  is  somewhat  toward 
one  or  other  end  of  the  rib  ;  and  the  rib  most  often 
broken  is  the  fifth  or   sixth.       Cases  are  recorded   of 


FRACTURES    AND     DISLOCATIONS.  15 

fracture  of  the  eleventh  or  twelfth  rib,  by  direct  violence 
As  regards  unusual  forms  of  fracture,  it  is  certain  that  there 
is  such  a  thing  as  true  sub-periosteal  fracture ;  or  the  ex- 
ternal or  internal  surface  alone,  or  the  upper  or  lower 
border  alone,  may  be  fractured ;  and  in  one  case 
of  this  kind,  the  intercostal  artery  was  lacerated.  One 
or  more  ribs  may  be  fractured,  probably  by  muscular 
effort,  remote  from  those  broken  by  direct  violence,  A 
rib  may  be  fractured  in  two  places,  and  the  fragment  dis- 
placed inward.  The  usual  division  of  fractures  of  the 
ribs  into  fracture  by  direct  violence  with  internal  dis- 
placement, and  fracture  by  indirect  violence  with  external 
displacement,  is  too  strict  to  suit  the  complex  character 
of  these  injuries.  As  Poland  has  pointed  out,  the 
same  violence  may  act  both  directly  and  indirectly ; 
and  in  seventy  specimens  of  fractured  ribs,  many  of  them 
plainly  due  to  indirect  violence,  Bennet  did  not  find  one 
that  showed  outward  displacement. 

Fracture  of  the  first  rib  is  very  rare;  but  I  have  had 
one  case  where  both  first  ribs  were  fractured,  toward  their 
middle,  by  a  fall.  Of  61  cases  (Poland),  44  were  between 
the  fourth  and  the  eighth  ribs,  13  among  the  last  four, 
and  4  among  the  first  three ;  in  only  9  was  the  fracture 
limited  to  a  single  rib. 

As  to  complications,  Poland  found  that  of  136  cases, 
ro8  were  free  from  complications,  16  had  emphysema 
(4  of  these  also  developed  pneumonia,  but  recovered),  3 
had  hemoptysis  with  emphysema,  3  severe  secondary  in- 
flammation, 6  died  at  once  from  shock.  These  figures 
are  more  encouraging  than  those  of  Settegast,^  who 
gives  20  cases  of  fracture  of  one  to  four  ribs  :  i  died 
of  delirium   tremens,    3   suffered   extensive   emphysema, 

'"  Langenbeck's  Archiv.,"  1879,  xxiii.,  274. 


i6  SURGERY    OF    THE    CHEST. 

3  traumatic  pleurisy,  4  pneumothorax  and  haemothorax, 
and  7  had  injury  of  the  lung.  I  do  not  remember 
to  have  had  a  death  from  simple  uncomplicated  fracture 
of  ribs. 

The  relation  of  old  age,  and  of  such  wasting  diseases 
as  phthisis,  scurvy  or  moUities  ossium,  to  fracture  of  the 
ribs,  and  the  strange  brittleness  of  the  bones  in  some 
individuals  or  some  families,  need  be  mentioned  only. 
Two  subjects  may  be  considered  at  some  length : 
these  are,  fracture  of  the  ribs  by  muscular  effort, 
and  fracture  in  the  insane. 

Malgaigne,  in  1841,  noted  that  'spontaneous'  frac- 
tures of  the  ribs  usually  occur  on  the  left  side,  and 
toward  the  anterior  end  of  the  rib.  Doubtless,  in  some 
of  these  cases,  the  rib  is  predisposed  to  fracture  by  old 
age  or  disease ;  but  the  same  thing  may  occur  in  young 
and  healthy  people.  It  has  arisen  from  a  severe  fit  of 
coughing ;  after  sneezing ;  in  the  pains  of  labour ;  on 
lifting  a  heavy  load ;  or  swinging  a  scythe  ;  and  during 
the  performance  of  acrobatic  feats.  Gurlt  ^  says  of  it, 
'When  we  consider  how  great  violence  the  ribs  can  with- 
stand, it  is  hard  to  understand  the  isolated  fracture  of 
one  or  two  of  them  by  mere  muscular  action.  Yet  I 
know  of  fourteen  cases.  Of  these,  ten  were  due  to  a 
violent  cough  ;  one  came  from  a  resolute  effort  to  keep 
back  a  sneeze,  one  from  turning  in  bed,  one  from  riding 
a  restless  horse,  one  from  the  patient's  attempt  to  save 
himself  from  slipping.  Age  and  general  health  have 
nothing  to  do  with  it.  In  three  of  the  cases,  two  ribs, 
next  each  other,  were  broken  ;  in  another  case,  the 
patient  on  three  successive  occasions  broke  one  each 
time,  each  rib  next  the  other.     Usually  the  lower  ribs 

'  "  Ueber  Knochenbruchen,"  i.,  216. 


FRACTURES    AND     DISLOCATIONS.  17 

are  thus  broken,  the  seventh  to  the  eleventh  ;  and  in 
ahnost  all  the  cases  they  were  broken  far  forward.' 
Two  of  Gurlt's  cases  will  serve  as  examples  of  this 
curious  accident.  A  strong,  hearty  man,  aged  40, 
standing  during  a  violent  cough,  was  suddenly  seized 
with  a  pain  in  his  side  so  severe  that  he  nearly  fainted, 
and  remained  for  some  time  unable  to  cough  or  move  ; 
he  had  fractured  the  eleventh  right  rib,  about  the  middle. 
A  man,  aged  39,  in  vigorous  health,  to  stop  a  fit  of 
sneezing,  drew  a  deep  breath  and  held  it.  At  the  moment 
of  sudden  expiration,  he  heard  a  rib  give  way,  and  was 
seized  with  severe  pain  in  the  left  hypochondrium, 
difficulty  in  breathing,  and  agonizing  cough  ;  there  was 
an  oblique  fracture  of  the  ninth  left  rib,  about  the 
middle. 

For  fracture  of  ribs  in  the  insane,  we  may  take  the 
figures  given  by  Gudden,i  Hearder,^  and  Wiglesworth. 
Gudden,  in  100  general  post-mortem  examinations  of  the 
bodies  of  the  insane,  found  16  cases  of  fractured 
ribs.  The  majority  of  the  patients  had  died  of  general 
paralysis.  In  one  instance  there  were  14  fractures, 
in  another  23,  in  another  30.  Hearder,  in  20  similar 
examinations,  found  well-marked  changes  in  the  ribs  in 
9  cases ;  they  were  thin,  brittle,  and  poor  in 
calcium  salts.  Wiglesworth,  in  30  examinations,  found 
only  8  cases  where  the  ribs  appeared  perfectly  healthy. 
In  17^  there  were  slight  changes,  chiefly  vacuolation 
of  the  bone,  '  the  general  failure  of  nutrition,  so  common 
in  insanity,  or  with  phthisis  or  senile  decay ' ;  in  3  only, 
were  found  '  clear  and  precise  lesions,  produced  by  con- 
siderable internal  absorption,   which  renders   the  bone 

■"Archiv.  f.  Psychiatrie,"  1870. 
'"Journal  of  Mental  Sciences,"  1871. 


i8  SURGERY    OF    THE    CHEST. 

very  porous  and  brittle,  and  sets  up  the  condition  known 
as  osteoporosis,  probably  having  a  causal  connection 
with  insanity.' 

In  T870,  Edward  Ormerod  wrote  an  admirable  account 
of  fractured  ribs  in  two  cases  :  one  a  woman,  aged  58, 
acute  mania  ;  the  other  a  man,  aged  46,  general  paralysis 
with  melancholia.  '  The  bones  were  brittle  and  soft, 
allowing  a  scalpel  to  be  passed  through  them.  When 
bent,  they  snapped  suddenly  with  a  clean  fracture  without 
spHntering.  All  the  strength  of  the  bone  lay  in  its  outer 
shell  of  compact  tissue,  which  yet  was  no  thicker  than 
cardboard.'  The  microscope  showed  fatty  and  granular 
degeneration  of  the  whole  bone,  with  dilatation  of  the 
Haversian  canals. 

In  1890,1  Dr.  Claye  Shaw  wrote  a  most  valuable  essay 
on  the  whole  subject.  He  tested  the  breaking-weight  of 
healthy  ribs,  fixing  their  heads  in  a  vice,  and  hanging 
weights  from  their  free  ends.  The  average  breaking 
weight  of  the  eighth  rib  was  about  15  lbs.  for  a  man,  10 
for  a  woman.  '  It  thus  appears  that  ribs,  taken  fresh 
from  a  body,  and  supported  only  at  one  end,  break  under 
a  comparatively  small  weight.  Weight-striking  machines 
are  graduated  up  to  500  lbs.,  and  we  may  reckon  300 
lbs.  as  representing  the  force  of  a  severe  blow.  Yet  even 
a  heavy,  powerful  man  is  unable,  by  the  strongest  blow 
he  can  give,  to  break  an  opponent's  rib  by  a  direct  blow, 
unless  it  is  delivered  when  the  opponent  is  placed  at 
a  disadvantage,  e.g.,  is  turning  sharply  round.'  The 
contrast  between  the  light  breaking-weight  of  a  rib 
removed  from  the  body,  and  the  heavy  direct  blows  in 
boxing,   which  yet   do   not    break    a    rib,    shows   that 

'"  St.  Bartholomew's  Hosp.  Reports,"  xxvi.,  p.  15.  See  also 
Dr.  Campbell's  paper  on  this  subject,  "Brit.  Med.  Journ," 
September  28,  1895. 


FRACTURES    AND     DISLOCATIONS.  19 

fracture  of  ribs  in  the  insane  is  due  not  to  the  violence 
of  their  attendants,  nor  to  any  special  structural  changes 
in  the  bones,  but  to  the  way  in  which  a  restless  or 
struggling  patient  throws  himself  into  such  a  posture 
that  a  very  slight  pressure  is  enough.  'The  dictum, 
that  the  ribs  of  the  insane  are  more  brittle  than 
those  of  the  sane,  is  true  to  a  very  limited  extent  only, 
and  is  almost  confined  to  those  affected  with  degenera- 
tion of  the  circulatory  system.' 

Mr.  Macnamara  ^  agrees  that  there  is  no  special 
disease  of  the  ribs  of  the  insane.  '  I  commenced  my 
researches,'  he  says,  '  fully  expecting  to  meet  with  some 
interesting  pathological  changes  in  the  bones,  but  I  have 
been  disappointed.  For,  as  I  worked  on  at  specimens  of 
this  kind,  I  gradually  arrived  at  the  conclusion  which  I 
now  hold,  that  neither  the  ribs  nor  other  bones  of  insane 
patients  are  liable  to  any  peculiar  abnormal  changes.  It 
seems  to  me  more  probable  that  the  injury  has  been 
caused  by  the  attendants  kneeling  on  the  patients'  chests 
to  keep  them  from  moving.' 

The  weight  of  evidence  seems  to  be  against  the 
occurrence  of  any  definite  changes  in  the  ribs  of  the 
insane  directly  due  to  insanity.  Also,  it  seems  certain 
that  an  insane  patient,  already  weak  and  wasted, 
may  expose  himself  to  fracture  of  a  rib  by  a  very 
slight  pressure  ;  just  as  one  has  heard  of  fracture  of 
a  rib  in  an  anesthetized  patient,  during  the  performance 
of  artificial  respiration.  It  is  to  be  noted  that  Gudden 
and  Hearder  wrote  a  quarter  of  a  century  ago,  when  the 
treatment  of  the  insane  was  very  different  from  what 
it  is  now. 

The  grave  dangers  and  difficulties  due  to  or  accom- 

'  "  Diseases  of  Bones  and  Joints,"  3rd  ed.,  p.  251. 


20  "  SURGERY    OF    THE    CHEST. 

panying  severe  fractures  of  the  ribs  and  injury  of  the 
whole  chest^pneumonia,  emphysema,  pneumothorax, 
laceration  of  lung  or  heart,  and  other  internal  injuries — 
will  be  considered  in  chapters  by  themselves.  A  case  of 
simple  fracture,  apart  from  all  these  troubles,  runs  a 
smooth  course,  and  non-union  is  a  thing  almost  impossible ; 
even  Gurlt,  in  his  great  work  on  fractures,  could  find 
only  three  instances  of  it. 

It  is  in  some  cases  almost  impossible  to  determine 
whether  a  rib  has  or  has  not  been  fractured  ;  as  when  the 
patient  is  very  fat,  intolerant  of  the  least  pain  of  examina- 
tion, or  half  drunk.  A  blow  with  the  fist  is  more  likely  to 
cause  contusion  than  fracture ;  a  crush  or  run-over 
accident,  if  pain  be  felt  about  the  middle  of  the  rib,  is 
more  likely  to  be  fracture  than  contusion.  There  is  often 
no  crepitus ;  as  when  the  rib  is  simply  cracked  across,  or 
the  broken  ends  have  slipped  one  over  the  other,  or  the 
soft  tissues  have  got  between  them.  The  right  method  of 
examination  is  to  feel  carefully,  inch  by  inch,  the  whole 
accessible  length  of  each  rib  ;  and  to  lay  one's  whole 
hand,  for  some  minutes,  over  the  seat  of  pain,  in  the  hope 
of  catching  a  chance  movement  of  the  broken  ends. 
One  is  not  likely  to  learn  anything  from  pressure  on  the 
two  extremities  of  the  rib.  If,  after  the  first  suffering  of 
the  injury  has  passed  off,  the  patient  still  complains  of  a 
sharp  pain,  always  in  the  same  place,  worse  on  coughing 
or  drawing  a  deep  breath,  and  seizing  him  suddenly  just 
at  the  end  of  the  inspiration  ;  if  his  respiration  is  still 
quick  and  shallow,  and  he  finds  ease  in  one  posture,  and 
not  in  another,  there  is  good  reason  for  believing  that 
one  or  more  ribs  are  broken. 

The  treatment  of  simple  fracture  of  ribs,  without  other 
injuries,  requires  all  common-sense  methods  that  may 
best    ensure    rest   in    bed,    easy    breathing,    light    diet, 


FRACTURES     AND     DISLOCATIONS.  21 

and  freedom  from  cough  and  pain  ;  and  it  is  of  great  im- 
portance that  aged  patients  should  not  be  kept  long 
on  their  backs.  The  necessary  restriction  of  the  move- 
ments of  the  chest  and  of  the  broken  ribs  may  be 
secured  as  well  by  a  well-adjusted  bandage  as  by 
strapping,  if  not  better  ;  and  this  saves  the  patient  from 
all  irritation  of  the  skin,  and  from  the  uncomfortable 
process  of  having  the  strapping  finally  removed.  The 
bandage  may  be  applied  from  the  lower  ribs  upward,  at  a 
moment  when  the  patient  has  just  emptied  his  lungs  of 
air;  but  this  rule  is  not  of  great  importance.  To  prevent 
the  bandage  from  slipping  down,  the  surgeon  should  first 
place  a  long  strip  of  broad  bandage,  with  a  slit  in  the 
middle,  over  the  patient's  head,  so  that  it  lies  round  his 
neck,  with  the  ends  hanging  down  in  front  and  behind  ; 
then,  having  applied  his  bandage  round  the  chest,  over 
the  strip,  he  turns  up  the  ends  of  the  latter  over  the 
bandage,  pinning  them  so  that  they  hold  it  in  its  place. 

We  should  remember  that  a  bandage  may  cause  pain 
instead  of  alleviating  it.  A  man^  broke  his  tenth  left 
rib  by  falling  against  a  table  :  when  lying  on  his  back, 
he  was  free  from  pain ;  but  when  a  circular  bandage 
was  applied,  he  suffered  so  much  pain  that  it  had  to  be 
removed.  In  this  case,  there  was  marked  displacement, 
which  disappeared,  with  a  crepitus,  when  he  coughed. 
In  such  cases,  a  bandage  must  not  be  used  ;  and  the 
patient  will  be  healed  just  as  well  without  it. 

Fractures  of  the  Costal  Cartilages. 

It  is  seldom  that  the  costal  cartilages  are  fractured, 
and  when  this  occurs  there  are  usually  other  injuries  of 
the    parts    beneath.      They    are,    as   a   rule,    fractured 

'  See  Nelaton's  "  Lectures  on  Surgery,"  Atlee,  1855,  p.  156. 


22  SURGERY    OF    THE    CHEST. 

by  direct  violence,  though  a  few  cases  have  also  been 
noted  of  fracture  by  muscular  effort.  The  fibrous  and 
calcareous  degenerations  of  old  age  may  be  predisposing 
causes.  The  usual  site  of  fracture  is  about  the  juncture 
between  rib  and  cartilage ;  but  this  is  not  a  true  joint, 
and  we  must  therefore  reckon  the  lesion  as  a  fracture, 
not  a  dislocation.  The  most  common  cause  is  a  fall 
against  some  such  obstacle  as  the  edge  of  a  table  ;  and 
the  cartilage  most  likely  to  be  fractured  is  the  eighth  ; 
those  next  above  it  are  more  often  broken  than  those 
below  it.  Usually,  the  sternal  fragment  is  displaced  in- 
ward, and  the  costal  fragment  outward.  Non-union  is 
very  rare,  but  some  few  cases  have  been  recorded.  In 
one,  suppuration  occurred  round  the  broken  ends,  which 
i^ecame  the  seat  of  necrosis  ;  they  were  resected,  but  the 
wound  did  not  heal,  and  the  patient  died  a  few  months 
later  of  tuberculosis. 

The  following  cases  from  Gurlt  illustrate  the  usual 
course  of  fracture  of  the  costal  cartilages  : — 

1.  A  man,  after  general  contusion  of  the  chest,  suffered 
pain  and  slight  dyspnoea,  and  the  4th  right  costal  cartilage 
was  found  driven  backward  and  downward  ;  deep  inspiration 
reduced  it,  but  expiration  again  displaced  it.  There  was  no 
external  bruise.  It  was  reduced,  kept  in  place  with  a 
bandage,  and  healed  without  any  trace  of  displacement. 

2.  A  young  man  struck  the  right  side  of  his  chest  against 
a  balustrade  ;  ten  days  later,  his  surgeon  found  a  fracture  of 
the  5th  right  costal  cartilage,  about  an  inch  from  the 
sternum.  When  the  patient  stood  up,  the  inner  fragment 
was  thrown  forward,  but  went  back  on  gentle  pressure  or  on 
deep  inspiration  ;  it  was  most  prominent  when  he  lay  on  his 
left  side,  less  when  he  lay  on  his  back,  least  when  he  lay  on 
liis  right  side.  Two  different  bandages  were  tried,  but 
failed.  Finally,  a  soft  compress  and  an  elastic  bandage  were 
applied,  with  an  elastic  air-pad  ;  with  these,  the  fracture 
healed  in  twenty  days  without  the  least  deformity. 

3.  A  man,  aged  33,  was  knocked  down  with  a  blow  on  the 
chest,  and  next  day  was  feverish,  with  pain,  made  worse  by 


FRACTURES     AND     DISLOCATIONS.  23 

every  movement  of  respiration.  There  was  a  hard  bruise, 
with  a  very  painful  central  spot  ;  the  4th  costal  cartilage  was 
fractured  about  half  an  inch  from  the  sternum  ;  the  inner 
fragment  was  depressed,  and  freely  movable.  By  means  of 
a  compress,  bandage,  and  tight  flannel  vest,  the  pain  was  re- 
lieved and  the  displacement  lessened.  The  fracture  healed 
in  a  month,  with  a  slight  smooth  oval  thickening  of  the 
injured  cartilage. 

A  very  severe  crush  of  the  chest  may  cause  extensive 
fracture  of  the  costal  cartilages,  and  yet  the  patient  may 
recover.  The  case  has  been  recorded  of  a  child,  7  or  8 
years  old,  crushed  between  a  cart  and  a  wall,  in  whom 
every  cartilage  down  one  side  was  fractured.  The  sternal 
fragments  were  displaced  forward;  they  went  back  on 
gentle  pressure,  but  it  was  hard  to  keep  them  in  position. 
A  man,i  after  a  like  accident,  had  fracture  of  all  the 
cartilages  of  both  sides,  '  so  that  his  chest  felt  like  that 
of  a  body  on  the  post-mortem  table,  when  the  costal  car- 
tilages have  been  divided  to  remove  the  sternum.'  The 
left  clavicle  was  also  dislocated  at  its  acromial  end.  His 
state  on  admission  seemed  hopeless.  He  was  bled  and 
bandaged,  and  in  twenty-five  days  made  a  good  recovery, 
with  only  slight  deformity. 

Non-union  of  fractured  costal  cartilage  has  been  noted, 
but  is  very  rare.  The  exact  process  of  union  has  been 
explained  in  more  ways  than  one.  Riedinger  is  of 
opinion  that  the  cartilage  itself  takes  no  part  in  it ;  the 
fragments  lie  inert,  rounded  off,  one  over  the  other, 
separated  by  fibrous  tissue ;  a  callus  of  spongy  bone, 
with  large  lacunae,  is  formed  round  them,  and  in  the  angle 
between  them. 

The  treatment  of  a  fractured  costal  cartilage  is  a  matter 
of  careful  reduction  and  fixation,  with  restriction  of  the 
chest  with  a  well-adjusted  bandage.    'If  we  cannot  reduce 

'  Sir  Chas.  Bell,  "Middlesex  Hosp.  Reports,"  1816,  viii.,  p.  171. 


24     ■  SURGERY    OF    THE    CHEST. 

the  displacement,  if  permanent  pressure  fails,  if  a  deep 
inspiration  does  not  reduce  it,  if  we  gain  nothing  by 
turning  the  patient  on  to  the  sound  side,  or  by  putting 
pillows  under  his  back,  we  have  come  to  the  end  of  our 
resources,  and  must  let  the  fracture  heal  with  deformity.' 

Dislocations  of  the  Ribs. 

It  is  plain  from  the  shape,  texture,  and  attachments  of 
the  ribs  that  they  are  easily  fractured  but  not  easily  dis- 
located. As  to  separation  of  the  head  of  a  rib  from  its 
articulations  with  the  spinal  column,  this  is  a  wonder  of 
the  posf  mortem  room,  and  it  has  not  been  found  possible 
to  produce  it  on  the  dead  body.  Nine  or  ten  instances 
have  been  collected  by  Riedinger  from  various  sources. 
In  one  only,  was  it  unaccompanied  by  other  severe  injuries. 
The  subjects  of  it  were  young,  the  oldest  being  44.  From 
the  fact  that  in  five  of  them  the  eleventh  rib  was  dis- 
placed, and  in  three  of  them  the  twelfth  rib,  it  is  plain 
that  the  displacement  is  due  to  great  external  violence. 
I  need  not  say  that  it  is  more  likely  to  be  found  after 
death  than  made  out  during  life. 

Dislocation  of  a  costal  cartilage  from  the  sternum  is 
also  very  rare.  I  lately  saw  a  case,  where  the  fourth  left 
cartilage  was  slightly  displaced  forward,  and  movable  : 
it  was  easily  replaced,  but  would  not  stay  in  position. 
Out  of  19  cases  collected  by  Riedinger,  the  fourth  cartil- 
age was  dislocated  in  6  :  the  fifth  in  4  :  the  sixth  in  4  :  the 
fourth,  fifth  and  sixth  all  together  in  3  :  and  the  second  in  2 
(one  of  these  was  double).  As  a  rule,  the  cartilage  is  dis- 
placed forward,  a  displacement  which  cannot  be  produced 
on  the  dead  body,  and  I  do  not  know  of  3.ny  post  mortem 
example  of  it.  'Sir  Charles  Bell  has  seen  it  produced 
by  violent  extension  of  the  arms  during  exercise  with 
dumb-bells  :  Bransby  Cooper  saw  a  luxation  of  the  fifth 


FRACTURES    AND     DISLOCATIONS.  25 

and  sixth  cartilages  in  a  Ijoy,  produced  by  the  constant 
action  of  the  pectorals  in  kneading  bread. '^  In  some 
cases,  it  is  hard  to  decide  whether  the  cartilage 
was  dislocated  or  fractured.  The  forward  displacement 
is  easily  reduced.  In  one  case,  where  three  cartilages 
were  thus  displaced,  reduction  was  effected  by  arching 
the  back  over  pillows  placed  under  it.  The  backward 
displacement  is  more  rare,  more  serious,  and  more 
diiificult  to  reduce.  The  usual  method  of  pressure  on  the 
sternum,  while  the  patient  takes  a  deep  breath,  may  fail. 
Nor  can  much  be  expected  from  the  ingenious  method  of 
Negretti,  who,  when  everything  failed,  dashed  cold  water 
over  the  patient's  face,  and  effected  reduction  during  the 
gasp  for  breath  that  followed. 

The  lower  cartilages,  the  sixth  to  the  ninth,  may,  it  is 
said,  be  displaced  :  but  probably  these  are  cases  of  fracture, 
not  of  dislocation.  From  the  cases  quoted  by  Poland, 
it  appears  that  the  displacement  is  due  to  sudden  violent 
effort  (lifting  a  heavy  weight,  struggling  to  avoid  falling) 
and  is  not  easily  reduced.  Forward  and  backward 
displacements  have  both  been  recorded. 

Fracture  and   Dislocation  of  the  Sternum. 

These  injuries  are  so  dangerous,  and  of  such  great 
interest,  that  they  have  at  all  times  had  a  special  attraction 
for  surgeons,  and  there  has  gathered  round  them  a  great 
wealth  of  literature.  They  are  seldom  seen  alone : 
Gurlt,  in  a  collection  of  more  than  fifty  thousand  fractures 
of  all  kinds,  found  only  fifty-two  fractures  of  the  sternum; 
Lonsdale,"  in  a  similar  collection  of  nearly  two  thousand, 
found  only  two.     Even  in  combination  with  other  injuries 

'Poland,  "Holmes'  and  Hulke's  System  of  Surgery."    i.  817. 
=  "Amer.  Journ.  Med.  Sciences,"  1S62,  p.  411. 


26  SURGERY    OF    THE    CHEST. 

(fractured  spine  or  ribs)  they  are  still  very  rare.  One 
might  suppose  that  a  bone  so  exposed  and  presented  to 
all  sorts  of  violence  would  often  be  broken,  but  the 
exquisite  curves  and  elasticity  of  the  ribs  and  their 
cartilages  allow  pressure  on  the  sternum  to  be  at  once 
distributed  far  and  wide  away  from  it.  Messner^  has 
found  that  in  the  dead  body  of  a  child  you  can 
make  the  sternum  touch  the  spine  without  breaking  any 
bone,  and  in  the  bodies  of  older  people  can  bring  them 
within  an  inch  or  two  of  each  other.  Again,  the  sternum 
moves  not  only  with  the  costal  cartilages,  but  also  to  some 
slight  extent  upon  them,  and  may  thus  yield  a  little  to 
any  crushing  weight ;  and  through  early  life  the  sternum 
itself  is  elastic,  and  not  yet  welded  together.  Hence,  out  of 
all  the  recorded  cases  of  fracture,  only  three  occurred  in 
patients  less  than  twenty  years  old. 

The  unusual  forms  of  simple  fracture  (longitudinal, 
oblique,  partial,  comminuted,  and  so  forth)  are  so  rare, 
that  the  only  form  to  be  noted  here  is  that  which  occurs 
between  the  manubrium  and  the  rest  of  the  bone. 
Fracture  or  displacement  of  the  ensiform  cartilage  must 
also  be  considered.  Compound  fractures  of  the  sternum 
do  not  come  from  protrusion  of  the  broken  bone  through 
the  skin,2  but  only  from  wounds  of  the  chest  wall. 

In  the  usual  form  of  displacement  of  the  sternum, 
the  bone  gives  way  at,  or  just  about,  the  line  between 
the  manubrium  and  the  rest  of  the  bone.  The  upper 
fragment  is  depressed,  the  lower  fragment  rides  over  it ; 
the  second  ribs  usually  go  with  the  manubrium. 

Is  this  a  fracture,  or  a  dislocation  ?  Poland  speaks  of 
it    as    the    latter.     'The    symptoms    are   liable    to    be 

' "  Elasticitat  der  Knochen,"  1880. 
^Gurlt  found  only  one  recorded  case  where  this  happened. 


Plate  i. 


.,1      '<r        < 


The  usual  form  of  Displacement  or  the  Sternum.  From  Gurlt,  Ueber 
Knochenbriichen,  vol.  i.  (The  small  piece  of  bone  behind  the  body  of  the 
sternum  is  a  fragment  that  has  become  re-united  to  it.) 


[Fttce  fi.  26. 


FRACTURES    AND     DISLOCATIONS.  27 

mistaken  for  fracture  at  or  about  the  same  level.  But  in 
dislocation  there  is  a  marked  projection  of  the  lower  frag- 
ment, and  this  can  be  recognized  as  the  articulating  sur- 
face by  its  three  smooth  articulating  facets,  one  central  for 
the  manubrium,  and  two  lateral  for  the  costal  cartilages.' 

Riedinger  and  Gurlt  make  no  mention  of  the  possibility 
of  feeling  these  facets,  and  treat  the  question  as  of  no 
importance.  The  signs  in  either  case  are  the  same,  and 
specimens  have  been  described  by  one  man  as  fracture, 
and  by  another  as  dislocation.  So  far  as  experiment  goes, 
we  find  that  even  where  there  is  a  distinct  sort  of  joint 
between  the  two  fragments,  we  still  fail  to  produce  a  true 
dislocation  ;  the  cartilage  may  be  left  on  the  upper  frag- 
ment, or  on  the  lower,  or  some  of  it  on  each.  If  there 
is  no  joint  at  all,  it  is  a  fracture;  if  there  is  a  joint,  it  is 
a  dislocation.  We  do  not  know  before  the  accident,  and 
cannot  tell  after  recovery,  whether  there  was  a  joint  of 
any  kind,  or  not. 

Brinton^  examined  30  specimens  of  the  sternum, 
and  found  in  3,  bony  ankylosis ;  in  7,  union  by  fibro- 
cartilage;  in  20,  a  true  joint  with  a  synovial  sac  (18  of 
the  20  had  a  single  sac,  2  had  a  double  sac,  and  i  had  a 
sac  communicating  with  the  articulations  of  the  second 
costal  cartilages). 

Rivington-  examined  100  specimens,  of  all  ages.  He 
found  bony  ankylosis  in  6 ;  fibro-cartilage  in  51;  true 
joint,  but  not  fully  developed,  in  11;  true  well  developed 
joint  in  32. 

Maisonneuve  found,  in  the  majority  of  the  specimens 
which  he  examined,  even  in  the  bones  of  the  aged,  a  true 
joint,  without  a  trace  of  ossification. 


'"Amer.  Journ.  Med.  Sciences,"  July,  1867. 
'"Med.  Chir.  Soc.  Trans.,"  1874,  Ivii.,  loi. 


28  SURGERY    OF    THE    CHEST. 

Each  segment  of  the  sternum  is  clothed  with  a  distinct 
layer  of  cartilage.  That  of  the  upper  segment  is  adherent 
to  the  second  costal  cartilages ;  that  of  the  lower 
is  continuous  with  the  facet  on  the  side  of  the  sternum 
for  the  second  costal  cartilage.  Therefore,  in  the  dis- 
placement of  the  sternum,  the  second  ribs  go  with  the 
manubrium. 

These  facts  show  plainly  that  we  ought  to  keep  the 
name  of  fracture  for  such  injuries  of  the  sternum  as 
occur  away  from  this  joint,  and  for  such  cases  as  that 
recorded  by  Rivington,  where  an  acrobat  falling  on  the 
back  of  his  head  broke  his  cervical  spine  and  drove  his 
chin  down  on  to  his  sternum.  An  oblique  fracture  was 
found,  from  a  point  between  the  first  and  second  costal 
cartilages  on  the  right  side  to  the  third  costal  cartilage  on 
the  left  side,  traversing  the  articulation  of  the  sternal  seg- 
ments, but  not  following  it.  The  usual  displacement  is, 
from  the  anatomical  point  of  view,  a  dislocation  rather 
than  a  fracture. 

There  are  many  different  explanations  of  the  manner 
in  which  this  displacement  is  produced.  Direct  violence 
is  of  course  easy  to  understand  in  some  cases  of  true 
fracture  of  the  sternum ;  but  when  direct  violence  is 
followed  by  the  displacement  of  the  manubrium  behind 
the  gladiolus  in  the  usual  way,  has  the  manubrium  been 
driven  in  behind  the  gladiolus,  or  has  the  gladiolus,  by 
the  elasticity  of  the  ribs,  or  by  some  forward  tilting  of 
itself,  been  thrust  forward  in  front  of  the  manubrium  ? 
Again,  in  such  displacement  after  falls  on  the  back,  is 
there  any  meaning  in  saying  that  the  displacement  was 
the  result  of  contrecoiip,  or  any  reason  for  attributing  it, 
as  Riedinger  does,  to  sudden  strong  contraction  of  the 
muscles  attached  to  the  sternum  ?  Or  is  it  not  rather  due 
to  forcible  flexion  or  extension  of  the  spine  thrusting  the 


FRACTURES    AND     DISLOCATIONS.  29 

ribs  forward?     Or  is  the  shock  transmitted  along   the 
clavicles  rather  than  the  ribs  ? 

Such  problems  are  easily  set.  The  weight  of  evidence, 
carefully  considered  by  Rivington,  may  be  formulated  in 
some  such  way  as  the  following  : — • 

1.  It  is  sometimes  impossible  to  say  what  is  direct 
violence,  and  what  is  indirect.  Probably,  in  most  cases 
of  direct  violence,  as  where  a  man  is  run  over,  the  gladio- 
lus is  carried  forward,  over  the  manubrium,  by  the  rebound 
of  the  bent  ribs.  One  can  hardly  see  how  direct  violence 
could  drive  the  manubrium  backward,  behind  the  gladio- 
lus. The  manubrium  is  only  a  square  inch  or  so  in  size, 
and  direct  violence  could  hardly  drive  back  this  small 
and  firmly  fixed  piece  of  bone  without  breaking  the 
clavicles  and  tearing  the  neck. 

2.  Driving  forward  of  the  chin  on  to  the  sternum 
may  produce  fracture,  but  such  cases  must  be  rare  indeed. 
It  could  hardly,  of  itself,  produce  the  usual  form  of 
displacement. 

3.  INIuscular  effort  may  cause,  or  help  to  cause,  frac- 
ture or  displacement  of  the  sternum — as  in  several  cases 
during  the  pains  of  labour,  and  in  the  case  of  an  acrobat, 
who  bent  himself  far  back  to  pick  up  a  weight  with  his 
teeth.  But  it  is  not  probable  that  muscular  effort  has 
much  to  do  with  fracture  or  displacement  of  the  sternum 
from  fracture  of  the  spine. 

4.  Sudden  extreme  flexion  of  the  spine,  as  by  the 
falling  of  a  heavy  weight  upon  it,  may  cause  displacement 
of  the  sternum. 1  In  such  cases,  the  upper  dorsal  spine 
is  usually  fractured.  The  force  is  probably  transmitted 
through  the  clavicles  as  well  as  the  ribs. 

'In  one  case,  the  sternum  was  thus  dislocated  by  a  bone-setter 
forcibly  flexing  the  patient's  spine  to  relieve  rheumatic  pains  in 
his  back. 


30  SURGERY    OF    THE    CHEST. 

5.  Sudden  extreme  extension  of  the  spine,  as  by 
falling  on  the  back,  may  cause  displacement  of  the 
sternum.  In  such  cases,  the  manubrium  being  restrained 
by  the  first  and  second  ribs,  the  gladiolus  is  carried  over 
it  by  the  longer,  more  movable,  lower  ribs. 

6.  In  the  usual  forms  of  fracture  and  displacement, 
the  anterior  ligaments  are  torn,  the  posterior  ligaments 
are  loosed  from  the  gladiolus,  and  uplifted  from  it 
by  the  manubrium.  The  periosteum  goes  with  the 
ligaments.  It  is  rarely  stripped  further  than  the  third 
ribs.  But,  in  fracture  from  direct  violence,  one  may  find 
the  posterior  ligaments  torn,  not  the  anterior. 

The  signs  of  fracture  or  displacement,  though  in  this 
or  that  case  they  may  be  absent,  are  as  a  rule  only  too 
evident :  marked  deformity,  pain,  swelling,  troubled 
breathing,  inability  to  move,  great  distress  and  oppression, 
rigid  flexion  of  the  cervical  and  upper  dorsal  spine — to 
all  these  may  be  added  emphysema,  haemoptysis,  signs  of 
laceration  of  the  internal  mammary  vessels,  or  of  the 
heart.  I  quote  from  Gurlt  a  few  cases  which  are  of 
interest,  as  illustrating  the  causes,  results,  and  treatment  of 
such  injuries.  It  is  worthy  of  note  that  in  two  of  them 
the  lower  fragment  was  displaced  not  forward  but 
backward. 

1.  A  man,  aged  37,  run  over,  had  slight  haemoptysis,  and 
that  night  was  ill  and  feverish.  On  admission  to  Hospital, 
four  days  after  the  accident,  he  was  suffering  from  lever, 
dyspnoea,  and  an  almost  incessant  cough,  with  blood-stained 
sputa.  The  soft  parts  over  the  sternum  were  much  bruised, 
and  the  whole  front  of  the  chest  was  emphysematous,  so  that 
it  was  impossible  to  make  an  accui-ate  examination.  He  died 
on  the  ninth  day.  Post  niorievi^  the  sternum  was  fractured 
through  its  middle  third,  and  there  was  a  quantity  of  coagu- 
lated blood  in  the  anterior  mediastinum. 

2.  A  man,  aged  23,  was  struck  a  heavy  blow  on  the  chest, 
and  the  upper  part  of  the  body  of  the  sternum  was  fractured. 
The  lower  fragment  was  displaced  mward,  and  lay  behind 


FRACTURES    AND     DISLOCATIONS.  31 

the  upper  fragment  :  he  suffered  from  dyspnoea,  with  intense 
pain  on  deep  inspiration.  Many  attempts  at  reduction  were 
made  in  vain.  After  several  days,  during  a  severe  fit  of  cough- 
ing, the  lower  fragment  suddenly  returned  into  place. 

3.  A  man,  aged  43,  was  crushed  between  a  cart  and  a 
wall.  The  sternum  was  fractured  across  the  middle  ;  the  lower 
fragment  was  displaced  inward,  and  locked  beneath  the  upper 
fragment.  He  was  collapsed,  with  shallow,  rapid  breathing, 
and  pain.  The  next  night,  while  turning  in  bed,  he  felt  some- 
thing snap,  and  his  dyspnoea  was  relieved.  The  displacement 
had  disappeared. 

4.  A  man,  aged  50,  fell  from  a  height,  and  on  recovering 
his  senses,  some  hours  later,  had  intense  sternal  pain,  worse 
on  movement  and  on  deep  breathing  :  his  head  was  bent  far 
forward,  and  he  could  not  put  it  straight.  For  several  days 
he  suffered  from  faintness,  tinnitus  aurium,  haemoptysis, 
dyspnoea,  and  retention  of  urine.  There  was  no  paralysis  of 
the  limbs.  On  admission  to  Hospital,  twelve  days  after  the 
accident,  his  head  was  bowed  so  far  forward  that  his  chin 
touched  his  sternum,  and  his  chest  hardly  moved  in  respira- 
tion. There  was  an  oblique  fracture  of  the  sternum ;  the 
upper  fragment,  which  was  slightly  movable,  was  displaced 
inward,  carrying  the  third  costal  cartilages  with  it.  The 
displacement  was  partly  reduced  by  keeping  him  on  his 
back  without  a  pillow.  He  recovered,  but  with  some 
deformity. 

5.  A  man,  aged  60,  leaping  from  some  height,  came  down 
heavily  in  a  sitting  posture,  and  fractured  his  sternum.  The 
manubrium  was  displaced  inward,  carrying  with  it  the  sternal 
end  of  the  second  left  costal  cartilage,  which  was  fractured. 
He  suffered  severe  sternal  pain,  worse  on  pressure  and  on 
deep  breathing.  He  was  kept  at  rest  for  a  fortnight,  with 
pillows  under  his  back,  and  firm,  steady  pressure  was  made 
over  the  lower  fragment.  In  a  month  he  was  fit  for  work 
again,  and  the  deformity  was  less  marked  than  at  the  time 
of  the  injury. 

6.  A  man,  falling  on  the  gunwale  of  a  boat,  fractured  his 
sternum  between  the  manubrium  and  the  rest  of  the  bone. 
The  manubrium  was  displaced  inward  ;  the  second  left  costal 
cartilage  went  with  it  ;  the  second  right  costal  cartilage  was 
left  behind,  projecting  under  the  skin.  He  suffered  severe 
pain  for  many  days  ;  and  three  weeks  after  the  injury  his 
breathing  was  still  laboured,  and  he  could  hardly  raise  himself 
in  bed.  Repeated  attempts  at  reduction  were  made  in  ^■ain, 
with  pillows  under  the   lumbar   spine,   and   extension    and 


32  SURGERY    OF    THE    CHEST. 

counter-extension  of  the  trunk.     An  operation  was  proposed, 
but  refused. 

7.  A  woman,  falling  from  a  ladder,  suffered  fracture  of 
the  sternum.  The  manubrium  was  displaced  behind  the 
gladiolus  ;  she  had  severe  dyspncea.  Many  attempts  at 
reduction  were  made  in  vain,  including  the  old  method  of 
laying  the  patient  backward  over  a  tub.  Finally,  she  was  set 
on  the  edge  of  her  bed,  an  assistant  put  his  knee  between  her 
scapulas  and  drew  her  shoulders  upward,  the  surgeon  pressed 
the  ribs  downward,  the  patient  took  a  deep  breath,  and  the 
fragments  returned  into  place. 

These  cases  are  all  worthy  of  observation ;  for  they 
put  in  a  clear  light  the  usual  signs  and  course  of  fracture 
or  dislocation  of  the  sternum.  As  regards  treatment,  I 
fear  the  surgeon  must  not  presume  on  the  possibility  that 
the  displacement  will  correct  itself;  though  he  would  be 
justified  in  leaving  it  to  itself  if  it  gave  no  trouble,  and  if 
the  patient  were  old  or  feeble,  or  unfit  for  active  treatment. 
The  cases  quoted  indicate  the  sort  of  postures  and  man- 
ipulations by  which  the  surgeon  may  hope  to  effect 
reduction  ;  the  careful  use  of  an  anaesthetic  may  also  help 
him.  Nor  do  I  see  why  we  should  scoff  at  the  idea  of 
putting  a  patient  backward  over  a  tub  any  more  than  we 
do  at  the  Trendelenburg  position  for  abdominal  operations. 

Again,  all  methods  of  dragging  at  the  fragments  with 
sharp  hooks,  or  levering  them  into  place,  are  now  con- 
demned past  appeal.  But  they  were  used  long  before 
Lister  had  made  a  new  thing  of  surgery.  What,  in  the 
present  day,  should  prevent  a  surgeon  from  cutting  down 
on  the  fragments,  reducing  the  displacement,  if  necessary, 
by  removal  of  bone  with  the  cutting-forceps  or  the  tre- 
phine, and  wiring  the  fragments  ?  There  is  the  fear  of 
opening  the  pleural  cavity,  or  of  letting  air  into  it,  if  it  be 
already  lacerated.  A  lacerated  pleura,  however,  is  healed 
in  two  or  three  days.  Only  in  rare  cases  could  an  opera- 
tion be  proposed ;   but,  at  least,  it   is  possible  that  an 


FRACTURES     AND     DISLOCATIONS.  33 

operation,  wrong  in  the  days  of  Malgaigne  and  Cooper, 
would  be  right  now,  for  the  relief  of  a  case  of  urgent 
dyspnoea,  intense  pain,  and  inability  to  move  about ;  and 
such  an  operation  might  avert  the  danger  of  mediastinal 
abscess — n,  calamity  which  not  unfrequently  follows 
fracture  of  the  sternum. 

On  the  other  hand,  it  must  be  recognized  that  a  patient 
may  recover  with  serious  permanent  deformity,  or  with 
non-union,  and  yet  enjoy  fair  health.  A  man  kicked  by 
a  horse,  suffered  comminuted  fracture  of  the  sternum, 
with  so  great  depression  of  the  fragments,  that  one 
could  lay  the  head  of  a  six-year-old  child  in  the 
hollow.  Two  years  later,  save  for  occasional  spitting  of 
blood,  he  was  quite  well,  and  respiration  and  circulation 
were  both  normal.  A  man,  who  had  suffered  fracture 
of  the  sternum  by  muscular  effort,  and  had  for  several 
months  been  strapped  up  in  plaster  by  an  amateur  sur- 
geon, two  years  later  had  non-union  of  the  fragments. 
The  lower  fragment,  lying  over  the  upper,  was  slightly 
movable  from  side  to  side,  but  he  had  no  trouble  from  it. 

Fracture   or   Displacement  of  the   Ensiform 
Process. 

Special  attention  was  given  by  the  older  surgeons  to 
this  injury,  because  of  certain  cases  where  inward  dis- 
placement of  the  cartilage  had  been  followed  by  signs  of 
pressure  on  the  stomach,  pain  in  that  organ,  and  persistent 
vomiting.  It  is  probable  that  they  exaggerated  the 
importance  of  this  curious  association  of  vomiting  with 
displacement  of  the  cartilage.  For  two  of  the  cases 
reported  by  them  occurred  in  pregnant  women,  and  the 
vomiting  may  have  had  no  close  relation  to  the  displace- 
ment. The  following  cases,  however,  appear  to  place 
the  fact  itself  beyond  dispute. 


34  SURGERY    OF    THE    CHEST. 

1.  A  man.  aged  28,  tell  forward  on  a  candlestick,  and 
drove  in  his  ensiform  cartilage  at  right  angles  to  the  spine. 
For  the  next  two  years  he  suffered  frequent  attacks  of  vomit- 
ing, occurring  every  fifth  or  sixth  day.  Operation  was  pro- 
posed, but  refused.  Twelve  years  later,  the  process  was  still 
at  a  right  angle  with  the  sternum,  pointing  straight  toward  the 
spine  ;  but  he  had  no  trouble  from  it,  save  pain  on  coughing. 

2.  A  boy,  aged  18,  had  his  ensiform  cartilage  driven  in  by 
a  blow.  He  suffered  frequent  vomiting,  which  continued  until 
the  cartilage  was  reduced  by  manipulation. 

3.  A  boy,  aged  19,  after  falling  forward  on  the  edge  of  a 
boat,  was  seized  with  shortness  of  breath,  pains  in  the  stomach, 
and  intractable  vomiting.  For  three  weeks,  in  spite  of 
treatment,  he  vomited  everything,  till  at  last  he  was  in  danger 
of  death.  Careful  examination  now  showed  for  the  first  time 
sHght  depression  of  the  ensiform  cartilage.  Nine  days  later, 
when  he  was  now  almost  exhausted,  an  incision  was  made 
alongside  of  the  process  into  the  peritoneal  cavity,  and  with 
a  blunt  hook  the  displacement  was  reduced.  He  immediately 
called  out  that  he  felt  such  relief  as  he  had  never  had  since 
the  injury.  The  vomiting  never  occurred  again,  and  he  made 
a  complete  recovery. 

Cases  of  lateral  or  forward  displacement  of  the  car- 
tilage have  been  recorded,  but  without  vomiting.  It  is 
to  be  noted  that  the  backward  displacement  may  in  some 
cases  be  reduced  by  manipulation.  If  this  fails,  and  if 
the  deformity  causes  pains  in  the  stomach  or  vomiting,  it 
should  be  reduced  by  operation.  A  case  of  non-union,  in 
a  man  aged  60,  has  been  recorded  by  Clarus.  The  carti- 
lage was  displaced  upward  and  toward  the  left  side.  Nine 
months  after  the  injury,  it  was  still  movable,  with  crepita- 
tion, but  gave  him  no  pain. 


35 


CHAPTER   IV. 

CASES  OF  SIMPLE  FRACTURE  WITH  INTERNAL 
INJURIES. 

The  internal  injuries  and  inflammations  that  may  attend 
or  follow  simple  fractures  of  the  ribs  or  sternum  are 
so  many  and  so  grave,  that  it  would  be  wearisome  to  con- 
sider them  all  in  one  chapter.  Most  of  them,  therefore, 
though  often  mentioned  here,  are  more  fully  discussed 
later.  At  present,  we  are  concerned  only  with  the  general 
course  and  treatment  of  those  most  anxious  cases  where 
the  fear  or  certainty  of  internal  injury  is  of  more  im- 
portance than  the  fracture.  It  may  be  convenient  to 
take  these  injuries  in  order,  according  as  the  pleura,  the 
vessels  of  the  chest-wall,  the  lungs,  or  the  heart,  may  be 
affected  ;  only  noting  that  practically  it  is  the  conjunction 
of  two  or  more  such  injuries  that  makes  these  cases  so 
serious  and  difficult. 

Injuries  of  the  Pleura. 

Fracture,  or  even  contusion  without  fracture,  may  be 
followed  by  acute  or  subacute  diffuse  inflammation,  tend- 
ing to  suppuration  in  the  loose  connective  tissue  between 
the  pleura  and  the  intercostal  muscles  (peri-pleuritis,  retro- 
costal  abscess,  phlegmon  endothoracica).  This  was  first 
described  by  Boyer,  in  1824,  under  the  title  of  "Abscess 
of  the  cellular  tissue  of  the  pleura"-  but  without  clearly 
distinguishing  it  from  tubercular  abscess.  'In  acute  cases, 
the  patient  suffers  sharp,  deep-seated  localized  pain,  fever, 
troubled  breathing,  and  a  dry  cough.  These  symptoms 
continue  unabated  for  several  days ;   then  they  become 


36  SURGERY    OF    THE    CHEST. 

less  marked,  and  the  patient  has  shivering  fits  now  and 
again.  Soon  a  doughy  swelHng  appears  at  the  seat  of 
pain,  and  goes  on  rapidly  to  fluctuation.'  Such  is  Boyer's 
account ;  an  acute  or  subacute  phlegmonous  inflamma- 
tion, marked  by  rigors,  feverishness,  oedema,  and  tending 
to  the  formation  of  thick  pus;  it  may  also  be  accompanied 
by  albuminuria.  It  very  seldom  penetrates  the  pleura,  but 
points  outward,  and  may  easily  be  mistaken  for  empyema. 
It  does  not,  however,  gravitate  downward ;  does  not  alter 
its  level  with  any  change  of  posture ;  does  not  become 
more  tense  during  violent  expiration  ;  there  is  no  separa- 
tion of  the  ribs,  no  displacement  of  the  heart,  and  no 
great  collection  of  pus.  Of  8  such  cases  collected  by 
Bartels,  4  died  :  but  his  paper  was  published  twenty-two 
years  ago.     It  must  be  treated  early  by  free  incision. 

A  more  common  .affection  of  the  pleura  after  fracture 
of  the  ribs  is  a  slight,  limited  irritation  or  inflammation  ; 
there  may  be  a  friction-sound,  and  slight  adhesions  may 
be  set  up  ;  but  I  have  never  known  any  further  trouble 
ensue.  Billroth  has  noted  it  in  to  cases  out  of  58. 
Israel  has  recorded  a  case  of  pleural  effusion  after  fracture 
of  ribs,  remaining  still  unabsorbed  four  months  after  the 
injury ;  it  was  then  punctured,  became  purulent,  and  the 
patient  died.  The  following  cases  quoted  by  Gurlt  serve 
to  show  that  a  very  copious  pleural  effusion,  serous  or 
purulent,  may  follow  simple  fracture  of  ribs. 

I.  A  boy,  aged  1 2,  fell  and  broke  the  fifth,  sixth  and  seventh 
ribs  on  the  right  side.  Six  days  later,  there  were  signs  of 
pleural  effusion  ;  and  on  the  tenth  day  the  sixth  space  was 
punctured,  and  6  ounces  of  serous  fluid  evacuated.  On  the 
fourteenth  day  and  following  days,  pus  was  let  out.  On  the 
seventeenth  day  he  died  ;  16  ounces  of  pus  were  found  in  the 
pleural  cavity,  and  the  lung  was  compressed  to  one-third 
of  its  proper  volume. 

•   2.     A  man,  aged  42,  fell  and  broke  the  seventh,  eighth  and 
ninth  ribs  on  the  left  side.     This  was  followed  by  a  pleural 


FRACTURES    WITH   INTERNAL    INJURIES.         37 

effusion  ;  on  the  thirteenth  day,  the  fifth  space  was  punctured, 
and  6  ounces  of  pus  were  let  out  ;  two  days  later,  10  ounces 
more.  He  died  the  next  day,  and  80  ounces  of  sero-purulent 
fluid  were  found  in  the  pleural  cavity.  The  lung  was 
so  compressed  as  to  be  wholly  useless. 

3.  A  man,  kicked  by  a  horse,  suffered  fracture  of  the  fourth 
and  fifth  left  ribs  ;  no  haemoptysis  ;  slight  emphysema.  On 
the  fourth  day,  he  had  acute  pleurisy  ;  and  on  the  ninth  day, 
there  were  plain  signs  of  a  large  pleural  effusion.  Nothing 
was  done  till  the  twenty-fourth  day,  when  there  was  bulging 
of  the  fourth  space,  with  fluctuation  ;  18  ounces  of  pus  were 
evacuated  by  puncture.     He  made  a  good  recovery. 

These  cases  happened  long  ago,  and  I  quote  them,  not 
for  the  sake  of  the  treatment,  but  to  show  that  one  must 
bear  in  mind  the  possibility  of  pleural  effusion  in  any  bad 
case  of  fractured  ribs.  Probably  slight  laceration  of  the 
pleura  frequently  occurs  without  any  bad  results.  Not 
long  ago,  in  the  body  of  a  man  who  died  of  other  in- 
juries, I  found  three  very  small  lacerations  beneath  three 
fractured  ribs  ;  through  two  of  these,  sharp  fragments 
projected  into  the  pleural  cavity ;  the  third  was  merely  a 
minute  crack  in  the  pleura.  But  I  have  never  seen  any 
widespread  laceration  of  the  pleura ;  it  does  not  split  far 
and  wide,  but  gives  way  just  where  the  fragments  are 
actually  driven  through  it. 

Injuries  of  the  Vessels  of  the  Chest  Wall. 

Wounds  of  the  intercostal  and  internal  mammary  arteries 

are  considered  in  a  subsequent  chapter  ;    for  they  are,  in 

almost  all  cases,  due  to  incision  or  laceration  of  the  chest 

wall.     But  it  is  at  least  possible  that  one  of  these  arteries 

should  be  wounded  or  cut  across  in  simple  fracture  of 

ribs  or  sternum,  as  in  the  following  cases  * . 

I.  A  man,  aged  30,  received  a  slight  blow  on  the  right  side 
of  the  chest,  and  an  hour  later  complained  of  pain  extending 
from  the  lowest  rib  up  toward  the  shoulder.     There  was  no 

^Turner,  "  Medical  Times  and  Gaz.,"  i860  ii.,  p.  607. 


38  SURGERY    OF    THE    CHEST. 

external  bruise.  He  was  admitted  to  Hospital,  and  four 
hours  later  fell  into  a  state  of  collapse,  with  cold  sweats,  con- 
tinuous vomitino,  small  pulse,  130,  often  imperceptible.  He 
died  in  seventeen  hours.  Pos/  jnor/em,  no  external  sign  of 
any  injury.  In  the  pleural  cavity  were  5  pints  of  blood, 
and  the  lung  was  collapsed.  The  only  injury  was  a  partial 
fracture  of  the  inner  aspect  of  the  eighth  rib,  with  slight 
abrasion,  and  a  minute  slit  in  the  pleura.  The  intercostal 
artery  itself  was  uninjured  ;  the  hitmorrhage  must  have 
come  from  a  small  branch  of  it  running  close  to  the  opening 
in  the  pleura. 

2.  A  case  is  reported  by  Gulliver,  of  fracture  of  the 
sternum,  where  both  internal  mammary  arteries  were  torn. 
Death  followed  from  extravasated  blood  pressing  on  the 
heart.     Gurit  records  a  similar  case. 

I  can  find  no  further  record  of  laceration  of  these 
vessels  in  simple  fracture  without  external  wound.  Still, 
the  possibility  of  it  should  be  borne  in  mind,  if  one  should 
have  a  case  of  fractured  ribs  with  hsemothorax,  but  with- 
out any  sign  of  laceration  of  the  lung. 

Injuries  of  the  Lung. 

The  numerous  and  dangerous  injuries  of  the  lung  that 
may  attend  simple  fracture  of  ribs  may  be  roughly 
divided  according  as  they  manifest  themselves  soon 
or  late  after  the  injury.  Haemoptysis,  emphysema, 
pneumothorax,  hsemothorax — these  show  themselves  at 
once,  or  soon  after  the  accident.  Bronchitis,  pneumonia, 
abscess,  or  gangrene,  or  hernia  of  the  lung,  come  later. 

But  this  division  has  no  practical  value,  and  the 
majority  of  the  above  lesions  are  discussed  further  in  this 
book.  We  will  here  take  only  a  general  practical  view 
of  such  cases  as  may  best  illustrate  the  character  and 
extent  of  the  danger  to  which  the  lung  is  exposed  in 
fracture  of  the  ribs. 

And  it  is  to  be  observed  that  these  injuries  are  not,  in 
most  cases,  due  to  direct  driving  inward  of  the  fragments 


FRACTURES    WITH   INTERNAL    INJURIES.         39 

of  bone  into  the  lung.  The  ends  of  a  broken  rib 
may  just  wound  the  surface  of  the  lung,  and  cause 
emphysema  or  pneumothorax ;  and  in  severe  comminu- 
ted fracture  of  the  chest  wall,  as  by  a  gunshot  wound, 
pieces  of  bone  may  be  forced  right  into  the  lung ; 
but,  as  a  rule,  any  deep  laceration  in  simple  fracture  of 
ribs  is  due  to  the  violence  that  broke  the  ribs,  not  to 
actual  entry  of  the  sharp  fragments  into  the  lung.  The 
following  two  cases  ^  will  illustrate  this  fact. 

1.  A  boy,  aged  \2,h,  was  run  over  and  admitted  to 
Hospital.  There  was  no  loss  of  consciousness,  no  vomiting, 
no  haemoptysis.  Two  hours  later,  severe  dyspnoea,  breathing 
rapid,  noisy,  and  painful  :  all  over  the  right  side  of  the  chest 
there  was  amphoric  sound,  with  metallic  tinkling  sounds. 
There  was  no  sign  of  any  fracture,  and  no  emphysema. 
Venesection  was  practised.  That  night  he  suffered  extreme 
oppression  nnd  restlessness  ;  next  day  his  respiration  was 
60,  pulse  140.  Venesection  repeated  ;  dry  cupping  over  epi- 
gastrium. He  became  delirious,  and  died  two  days  later. 
Post  !Jiortc/n,  the  outer  surfaces  only  of  the  third  and  fourth 
left,and  third  right  ribs  were  cracked,  so  that  the  ribs  could 
be  pushed  a  little  way  inward  ;  their  periosteum  was  not  torn  ; 
the  pleura;  were  not  injured.  The  right  lung  was  lacerated  in 
two  places,  the  right  pleural  cavity  contained  8  or  g  ounces 
of  blood,  and  a  quantity  of  air,  and  was  covered  with  a  soft 
thick  false  membrane. 

2.  A  man,  aged  24,  run  over,  was  brought  four  miles 
in  a  cart  and  admitted  to  Hospital.  He  was  not  much 
collapsed  ;  there  was  no  sign  of  fracture  ;  no  haemoptysis  ; 
pain  over  the  liver  and  in  the  epigastrium.  Next  day  he 
was  better,  but  still  had  severe  pain  in  the  same  region,  and 
two  days  later  he  was  slightly  jaundiced,  and  the  urine  was 
deeply  stained  with  bile.  On  the  fifth  day  he  suddenly  became 
much  worse,  with  profuse  sweating,  intense  epigastric  pain, 
rapid  laboured  breathing,  pulse  intermittent,  130  ;  and  there 
were  signs  of  air  in  the  left  pleural  cavity,  with  extreme  dulness 
over  the  lower  part  of  the  lung.  Next  day  the  pleura  was 
punctured  with  a  trochar  and  cannula.  '  Just  before  the 
operation,  metallic  tinkling   and  amphoric  resonance    were 

'  Marjolin,  quoted  by  Gurlt,  loc.cit.;  McDonnell,  "Dublin 
Quarterly  Journal,"  1864,  xxxviii. ,  p.  205. 


40  SURGERY    OF    THE    CHEST. 

heard  for  the  first  time,  leaving  no  doubt  as  to  the  existence 
of  a  wound  of  the  lung.'  More  than  a  pint  of  blood  was  let 
out,  with  a  large  quantity  of  air.  His  relief  was  great, 
his  pulse  ceased  to  intermit,  and  he  slept  well.  He  gradually 
got  weaker,  and  died  with  acute  bronchitis  of  the  opposite 
lung,  ten  days  after  the  accident.  Post  mortem.,  heart  and 
mediastinum  displaced  toward  right  side,  diaphragm  so 
pushed  downward  as  to  lie  well  below  the  costal  cartilages  ; 
air,  and  at  least  3  quarts  of  blood,  in  the  left  pleura. 
'  The  left  lung  was  lacerated  in  a  terrible  way,  a  large 
portion  of  it  being  nearly  torn  off.  It  appeared  as  if  a  part 
of  the  lung  had  been  adherent  when  rent  off  by  the  shock.' 
There  was  no  fracture  of  the  ribs.  '  About  an  hour  or  two 
before  his  death,  some  clots  of  blood  were  coughed  up  ;  but 
before  that  time  no  heemoptysis  occurred.' 

These  two  most  interesting  cases  clearly  show  that  the 
lung  may  be  fearfully  lacerated  even  without  fracture  of 
the  ribs ;  and  that  where  the  ribs  are  fractured,  we  still 
cannot  decide  the  nature  or  extent  of  the  internal  injury. 
Indeed,  we  have  no  sign  of  any  kind  that  can  enable  us 
to  make  a  clear  estimate  of  it.  Hsemoptysis  was  absent 
in  these  two  cases,  and  in  a  similar  one  of  my  own, 
which  I  give  on  page  44,  beside  others  recorded  by 
Erichsen  and  Morel-Lavallee.  Heemothorax  is  a  surer 
guide,  and  will  be  considered  later. 

Still,  the  occurrence  of  hgemoptysis  can  lead  us  to  a 
fairly  accurate  idea  of  what  has  happened.  A  slight 
degree  of  contusion  or  concussion  of  the  lung,  rather 
than  actual  laceration,  is  very  common  in  these  cases  ; 
as  in  an  old  man,  lately  under  my  care,  who  broke 
several  of  the  upper  ribs  on  the  left  side,  near  the  axilla. 
His  sputa  were  blood-stained  for  the  first  two  or  three 
days,  then  rusty,  then  normal,  and  no  further  trouble 
followed.  '  In  these  cases,  the  lung  is  ecchymosed  at 
the  time  of  the  injury,  and  the  blood  extravasated  in  its 
tissue  gradually  breaks  down.  At  first,  the  sputa  are  of 
mucus  untinged  with  blood  ;  after  some  days,  the  patient 


FRACTURES    WITH   INTERNAL   INJURIES.         41 

coughs  up  a  small  quantity  of  dark,  coagulated,  viscid 
blood — very  different  from  the  florid,  frothy  sputum  of 
recent  lung-wound ;  and  the  sputa  may  be  tinged  with 
blood  for  some  time  afterward.  If  the  surface  only  of 
the  lung  is  injured,  the  bleeding  may  be  very  slight. 
When  it  is  abundant,  the  patient  spits  up  large  quantities 
of  florid  frothy  blood,  a  considerable  quantity  of  which 
may  be  swallowed  and  subsequently  vomited.  If  it  do 
not  prove  fatal,  this  bloody  expectoration  generally 
ceases,  in  a  great  measure,  in  the  course  of  forty-eight 
hours,  giving  way  to  sputa  of  a  rusty  character.''  But  in 
laceration  of  the  lung  by  a  heavy  weight,  as  in  these  cases 
of  fractured  ribs,  the  torn  vessels  of  the  lung-tissue  are 
less  likely  to  bleed  into  the  bronchial  tubes  than  in  cases 
of  penetrating  wound  of  the  chest  with  a  sharp  instrument. 

The  following  cases  illustrate  serious  but  not  fatal 
laceration  of  the  lung  in  simple  fracture  of  ribs  : — 

I.  A  woman,  aged  24,  run  over,  was  admitted  to  Hospital 
unaer  my  care,  much  collapsed,  with  fracture  of  two  ribs  on 
the  right  side  of  the  chest,  far  back  toward  the  spine  ;  she 
was  spitting  blood  rather  freely,  and  loud  rales  were  heard 
over  that  side  of  the  chest.  With  complete  rest,  and  careful 
nursing,  she  did  well  for  a  week  ;  the  hiemoptysis  came 
gradually  to  an  end,  and  she  was  beginning  to  sit  up  in  bed. 
On  the  eighth  day,  she  was  more  weak  and  ill,  and  had  in- 
crease of  pain  in  the  side  ;  temperature  102,  respiration  50  ; 
signs  of  pneumothorax  over  front  of  chest  ;  behind,  signs  of 
a  circumscribed  effusion.  On  the  thirteenth  day,  an  aspira- 
ting needle  was  put  in  at  the  fifth  space,  near  the  angle  of  the 
scapula,  and  8  ounces  of  dark  fluid  blood  were  drawn  ofif. 
This  gave  her  great  relief ;  but  on  the  nineteenth  day  it  was 
necessary  again  to  aspirate,  and  this  time  the  blood  that  was 
evacuated  was  mixed  with  ofTensive  pus.  A  week  later,  I 
made  a  free  incision,  letting  out  6  or  7  ounces  of  thin 
brown,  turbid,  offensive  fluid,  mixed  with  pus,  and  put  in  a 
large  tube.  No  more  fluid  carne  during  the  operation,  but  a 
iew  hours  later  there  was  a  profuse  rush  of  it,  soaking  the 
bed.     She  did  well;  the  tube  was  left  out  on  the  seventh  day. 

'  Erichsen,  "  System  of  Surgery,"  ii.,  p.  829 


42  SURGERY    OF    THE    CHEST. 

2.^  A  man,  aged  26,  was  kicked  on  the  left  side  of  the 
chest,  and  suffered  fracture  of  the  fifth  and  sixth  left  ribs. 
Forty-eight  hours  later,  he  began  to  spit  blood,  and  was  ad- 
mitted to  Hospital.  On  admission,  he  was  'coughing  and 
bringing  up  venous  blood  continually.'  Next  day,  he  was 
restless  and  in  a  very  bad  way  ;  temp.  I03'4  ;  '  expectoration 
profuse,  and  almost  entirely  made  up  of  blood.'  The 
following  day,  there  was  dulness  up  to  the  upper  angle  of  the 
scapula,  and,  with  the  stethoscope  put  just  below  the  nipple, 
air  could  be  heard  entering  the  pleural  cavity  from  the  lung. 
A  week  later,  a  swelling  came  below  the  nipple  ;  it  was 
aspirated,  and  a  small  quantity  of  blood-stained  purulent 
fluid  was  withdrawn  ;  incision,  two  days  later,  let  out  4  or  5 
ounces  of  pus.     He  made  a  good  recovery. 

3.-  A  boy,  aged  16,  run  over,  was  admitted  to  Hospital 
with  fracture  of  sixth,  seventh  and  eighth  right  ribs  just  in 
front  of  their  angles.  Three  hours  later,  he  coughed  up  some 
blood,  and  next  day  '  was  coughing  up  large  quantities  of 
blood';  general  condition  very  bad,  pulse  120,  respiration 
60,  but  temperature  normal.  On  the  ninth  day  the  haemo- 
ptysis had  stopped  ;  on  the  tenth  he  got  out  of  bed  without 
leave  ;  on  the  eleventh  the  haemoptysis  returned,  there  were 
signs  of  fluid  in  the  pleura,  and  he  had  a  rigor  ;  temperature 
102,  P.  140,  R.  66.  Next  day  he  was  aspirated,  and  3 
pints  of  blood-stained  fluid  were  withdrawn.  On  the  seven- 
teenth day  there  were  again  signs  of  fluid,  and  above  the 
level  of  the  fluid  there  was  tympanitic  resonance,  with 
amphoric  breathing  and  metallic  tinkling  sounds.  On  the 
twenty-first  he  was  again  aspirated — a  quart  of  blood-stained 
fluid  ;  and  again  on  the  twenty-third — 12  ounces  of  puru- 
lent fluid.  Free  incision  was  now  made,  and  i^  pints  of 
purulent  fluid  was  let  out,  with  a  quantity  of  air.  This  was 
followed  by  pneumothorax  of  the  whole  side.  He  made  a 
good  recovery. 

These  three  cases  give  a  vivid  picture  of  serious  but 

not  fatal  laceration  of  the  lung  in  simple  fracture  of  ribs. 

As  one  reads  them,  the  question  arises  why  incision  was  so 

long  delayed.     In  my  own  case,  there  were  two  reasons  : 

first,  the  patient  was  steadily  gaining  ground,  in  spite  of 

the  state  of  her  chest ;    next,   I  was  afraid  that  the  ad- 

'  Hird,  "  Med.  Times  and  Gaz.,"  1878,  ii.,  p.  514. 
^Walsham,  "  Med.  Times  and  Gaz.,"  1884,  i.,  p.  452. 


FRACTURES    WITH   INTERNAL   INJURIES.         43 

ministration  of  an  anaesthetic  might  cause  the  haemopty- 
sis to  return.  They  also  show  clearly  the  need  of 
absolute  rest,  very  careful  nursing,  and  so  forth.  It  is 
possible  that  the  haemoptysis  may  be  checked  by  subcu- 
taneous injections  of  morphia,  or  by  the  careful  use  of 
ice  to  the  side  of  the  chest. ^  How  common  these  cases 
are,  is  shown  by  Settegast's  report,  already  quoted.  Out 
of  20  Hospital  cases  of  simple  fracture  of  ribs,  3  had 
extensive  emphysema,  3  traumatic  pleurisy,  4  pneumo- 
thorax and  haemothorax,  and  7  severe  injury  of  the  lung, 
giving  rise  to  haemoptysis,  bronchitis,  and  '  oedema  of 
the  lung.'  Out  of  8  cases  of  simple  contusion  without 
fracture,  2  had  traumatic  pleurisy,  2  pneumothorax  and 
htemothorax,  and  i  of  these  had  '  several  attacks  of 
oedema  of  the  lung.' 

V/e  have  now  to  consider  that  form  of  pneumonia  with 
bronchitis  that  is  so  perilous  in  cases  of  fractured  ribs. 
The  term  '  oedema  of  the  lung  '  is  unsuited  to  it,  and  is 
best  kept  either  for  the  acute  general  cedema  of  both 
lungs  which  may  occur  apart  from  any  injury  of  the  chest, 
or  for  that  strange  'serous  oedema,'  with  albuminous 
sputa  (see  the  chapter  on  Pleural  Effusions  other  than 
Empyema)  which  follows  sudden  release  of  a  compressed 
lung  by  evacuation  of  a  pleural  effusion.  The  consolida- 
tion of  a  contused  lung,  some  days  after  injury,  is  a  true 
pneumonia,  not  a  passive  process.  The  following  cases 
illustrate  the  character  of  this  most  dangerous  condition : — 

I.  A  man,  aged  39,  heavy,  unhealthy,  and  a  drunkard, 
was  admitted  to  Hospital  under  my  care,  having  fallen  out  of 


"  Bamberger  recommends  the  following  mixture  : — Turpentine, 
5j  ;  oil  of  sweet  almonds,  5j ;  mucilage  of  acacia,  5iv  ;  syrup,  5iv  ; 
water  to  5v.  A  teaspoonful  every  half  hour  ("  Journ.  Amer.  Med. 
Ass.,"  June  6th,  1891).  See  Dr.  West's  paper,  quoted  in  the 
chapter  on  Tubercular  Phthisis,  for  the  whole  subject  of  treat- 
ment of  profuse  haemoptysis 


44  SURGERY    OF    THE    CHEST. 

a  cart  while  drunk,  and  fractured  four  or  five  inbs  on  the 
right  side  ;  he  had  also  a  scalp  wound,  and  displacement  ot 
sternal  end  of  right  clavicle.  He  was  unconscious,  his 
breathing  was  stertorous,  and  there  were  signs  of  chronic 
bronchitis,  with  profuse  muco-purulent  sputa  ;  no  haemopty- 
sis. Two  days  after  admission,  his  temperature  rose  to  102, 
and  his  sputa  were  rusty  ;  next  day  there  were  physical 
signs  of  pneumonia  of  the  left  base,  and  he  was  delirious. 
He  was  now  bled  by  the  resident  medical  officer,  to  8 
ounces  only.  There  was  at  once  marked  improvement,  and 
he  made  a  good  recovery. 

2.  A  woman,  aged  50,  was  admitted  to  Hospital  under  my 
care,  run  over,  having  suffered  fracture  with  depression  of  the 
third,  fourth  and  fifth  ribs  on  the  right  side,  below  the  breast. 
There  was  also  free  bleeding  from  the  vagina,  and  blood  was 
oozing  from  the  os  uteri.  The  vagina  was  plugged  ;  the  in- 
jured side  of  the  chest  was  strapped.  Her  temperature  on 
admission  was  subnormal,  but  next  day  it  was  loi ;  and  on 
the  third  day  there  were  signs  of  bronchitis.  On  the  fourth 
day  the  temperature  was  over  103,  and  next  day  the  sputa 
were  rusty,  and  she  was  somewhat  cyanosed.  The  following 
day  there  was  dulness  over  the  right  side,  with  loss  of  vocal 
vibration,  and  she  lay  on  this  side  ;  respiration  laboured,  52, 
temperature  io2'2.  Leeches  were  applied,  but  did  no  good. 
On  the  eighth  day  she  was  worse  in  every  way  :  dulness 
over  the  whole  right  side  ;  loud  rales,  tubular  breathing, 
56,  temperature  103.  She  died  on  the  tenth  day.  Venesec- 
tion was  proposed  in  this  case,  but  she  was  thought  to  be  too 
weak  to  stand  it. 

It  is  hard  to  say  whether  pneumonia  and  bronchitis 
are  or  are  not  cornmon  in  cases  of  simple  fracture  of  ribs. 
To  judge  by  Settegast's  figures,  they  are  common  ;  but 
Poland,  out  of  136  cases  of  fractured  ribs,  found  only  28 
complicated  with  internal  injuries,  and  of  these  only  4 
had  pneumonia,  none  of  whom  died ;  3  others  had 
'  extensive  injury  and  severe  inflammatory  symptoms.' 

I  add  another  case,  where  the  lung  was  lacerated,  on 
account  of  the  great  temporary  relief  given  by  venesection. 

A  man,  aged  45,  heavy,  gouty,  and  subject  to  bronchitis 
was  admitted  to  Hospital  under  my  care,  having  beer 
crushed  by  the  capsizing  of  a  heavy  carriage.     He  suffered 


FRACTURES    WITH   INTERNAL    INJURIES.         45 

fracture  of  many  ribs  on  both  sides,  and  bad  compound 
fracture  of  the  leg.  Severe  collapse,  no  hjtmoptysis.  On 
the  third  day  his  breathing  became  so  rapid,  and  his  pulse 
so  rapid  and  violent,  that  he  was  bled,  to  a  few  ounces  only  ; 
and  again,  that  evening,  to  9  ounces.  He  was  immediately 
much  relieved,  and  got  some  sleep  ;  and  as  the  first  blood 
was  flowing,  he  said,  "  Now  I  begin  to  feel  more  com- 
fortable." But  the  relief  was  only  for  a  time  :  he  became 
delirious,  with  respiration  152,  pulse  142,  weak  and  not  easily 
counted,  and  died  on  the  fifth  day  after  the  accident,  fosi 
morfe?H,  thirteen  ribs  were  found  broken,  seven  on  one 
side,  six  on  the  other  ;  there  was  severe  laceration  of  the 
right  lung,  with  h?emothorax.  There  was  also  a  minute 
heemorrhage  into  the  left  half  of  the  pons  Varolii,  and  some 
loss  of  power  of  the  right  arm  was  noted  dunng  life. 

So  far  as  I  know,  there  is  nothing  in  the  literature  of 
modern  surgery  as  to  the  use  of  venesection  in  surgical 
cases.  But,  as  regards  the  class  of  cases  with  which  we 
are  now  concerned,  there  is  abundant  evidence  that 
venesection  may  bring  immediate  relief,  or  may  even,  so 
far  as  we  can  judge,  save  the  patient's  life.  Poland  speaks 
thus  of  it :  '  Venesection  is  employed,  on  rare  occasions, 
for  the  relief  of  alarming  chest  symptoms,  which  threaten 
to  terminate  fatally  by  asphyxia  ;  the  chief  indications  foi 
its  use  being  increasing  dyspnoea,  oppressed  circulation, 
engorgement  of  the  lungs,  and  insufficient  aeration  of  the 
blood,  as  exhibited  by  the  dusky  countenance,  cyanosed 
lips,  and  hard  pulse.  In  these  cases  it  acts  quickly  and 
like  a  charm,  and  blood  should  be  taken  freely  until  the 
distressing  symptoms  are  relieved,  and  the  venesection 
repeated  if  they  recur.'  But  he  adds  that  out  of  his  136 
cases,  only  3  required  venesection.  Still,  only  28  of  the 
136  had  internal  injury  of  any  kind  ;  we  may  therefore 
reckon  that  3  out  of  28,  at  least,  were  in  urgent  need  of 
venesection. 

Gurlt  says  :  '  We  cannot  stop  short  at  bandaging,  in 
cases  of  severe  fracture  of  ribs  with  hsemothorax,  pneumo- 


46  SURGERY    OF    THE    CHEST. 

thorax,  emphysema,  hgemoptysis,  and  so  forth.  We  have 
to  face  the  immediate  danger  of  death.  In  ahiiost  every 
case,  we  must  bleed  the  patient  freely.  In  many  of  these 
complicated  cases,  when  once  we  have  got  the  patient 
past  the  stage  of  shock,  a  free  venesection  will  not  only 
relieve  the  dyspnoea  and  the  oppressive  feeling  of  suffoca- 
tion, but  will  also  stay  the  haemorrhage  from  the  lungs. 
The  flow  of  blood  must  be  stopped  as  soon  as  it  has 
done  definite  good ;  but  it  must  in  some  cases  be 
repeated,  or  local  depletion  must  be  used.' 

And  Solly,  speaking  of  similar  cases,  says  :  '  The  most 
important  lesson  which  these  cases  have  appeared  to  me 
to  teach  has  been  the  extreme  value  of  depletory  treat- 
ment generally,  and  more  especially  of  blood-letting.' 

Doubtless  the  use  of  venesection  in  internal  injuries  of 
the  chest  was  in  former  days  indiscriminate  and  often 
harmful ;  but  he  who  will  read  the  essays  on  venesection 
from  a  medical  point  of  view,  by  Dr.  Bowditchi  and 
Sir  B.  W.  Richardson,-  and,  above  all.  Dr.  Pye-Smith's 
paper  in  the  Transactions  of  the  Medico-Chirurgical 
Society  for  1891,^  will  find  proof  that  in  the  surgery  of  the 
chest  cases  now  and  again  occur  where  it  is  the  clear 
immediate  duty  of  the  surgeon  to  bleed  the  patient. 

Finally,  is  there  any  reason  to  think  that,  in  a  case  of 
simple  fracture  of  ribs  with  internal  injury,  the  surgeon 
could  ever  be  justified  in  attempting  to  expose  the  lung 
and  arrest  the  hsemorrhage  from  it  ?  There  is  abundant 
proof,  in  the  chapter  on  Penetrating  Wounds  of  the  Chest, 
that  this  may  be  done,  and  the  patient  saved  from  death, 

'Massachusetts  Medical  Society,  June  1871. 

^Opening  Address,  Medical  Society  of  London,  1868. 

3  Dr.  Pye-Smith  gives  notes  of  49  cases  treated  by  venesection. 
The  result,  in  31  cases,  was  marked  reHef.  Of  the  49  cases,  13 
were  cases  of  bronchitis,  several  of  which  were  complicated  with 
some  degree  of  lobar  pneumonia. 


FRACTURES    WITH   INTERNAL   INJURIES.         47 

in  cases  where  the  lung  has  been  cut  by  a  deep  incised 
wound.  Can  we  hope  to  save  life  by  operating  for  lacer- 
ation of  the  lungs  in  simple  fracture  of  the  ribs  ? 

We  may  exclude  the  possibility  that  the  blood  in  the 
pleural  cavity  in  such  cases  has  come,  not  from  the  lung, 
but  from  a  torn  intercostal  artery.  I  know  only  one 
instance  where  this  happened  (page  37).  If  we  did 
get  a  case  of  simple  fracture  of  ribs,  with  extensive 
h^emothorax,  but  without  hemoptysis,  and  without 
pneumothorax,  we  might  suspect  the  blood  came  from 
a  torn  intercostal  artery,  but  we  should  probably  find  it 
was  from  the  lung  after  all. 

The  fracture  cannot  tell  us  either  the  situation  or  the 
extent  of  the  laceration  of  the  lung.  If  this  be  slight,  the 
hsemorrhage  will  not  be  fatal.  If  severe,  the  risks  of  the 
operation,  and  the  difficulty  of  dealing  with  a  half- 
shattered  lung  hidden  in  and  beneath  a  mass  of  adherent 
clot,  in  a  patient  already  enfeebled,  feverish,  and  ill- 
suited  for  an  anaesthetic,  would  be  enormous.  I  can  find 
no  record  of  any  such  attempt,  and  it  is  hardly  possible 
that  it  would  be  justified. 

Hcemothorax,  Pntumothorax,  and  Emphysema. — 
These  lesions  are  fully  considered  in  other  chapters,  and 
in  that  on  Wounds  of  the  Lung ;  we  have  here  only 
to  note  their  occurrence  in  cases  of  simple  fracture. 
Cases  of  hsemothorax  have  already  been  given.  In 
such,  there  is  usually  air  as  well  as  blood  in  the  pleural 
cavity  (hsemopneumothorax),  and  it  is  often  followed  by 
inflammation  of  the  pleura,  tending  to  suppuration. 
But,  according  to  Pagenstecher,i  hjemothorax  does  not 
of  itself  set  up  this  inflammation  :  the  two  things  are 
independent,  and  are  both  due  to  the  original  injury. 

'"  Beitrage  z.  Klin.  Chir.,"  1895,  ^iii-«  i>  P-  264. 


48  SURGERY    OF    THE    CHEST. 

The  two  following  cases, i  one  of  haemothorax  and 
emphysema,  the  other  of  double  hsemothorax,  followed 
by  thrombosis,  are  of  great  interest. 

A  man,  aged  45,  was  struck  by  the  shaft  of  a  cart  on  the  left 
side  of  the  chest,  toward  the  scapula  ;  the  fifth,  sixth  and 
seventh  ribs  were  driven  inward.  Over  them,  between  scapula 
and  spine,  was  a  large  emphysematous  swelling,  which  rose 
and  fell  with  respiration  ;  and  there  was  general  emphysema 
of  the  whole  side  down  to  the  hip.  He  found  relief  by  lying 
with  his  face  downward,  and  his  ai-ms  under  him.  He  was 
in  much  pain,  with  cold  hands  and  feet,  feeble  pulse,  and 
difficult  breathing.  An  incision  was  made  into  the  swelling, 
a  quantity  of  air  was  let  out,  air  was  heard  escaping  from 
the  lung,  and  with  the  finger  a  broken  rib  was  felt  pressing 
on  the  lung.  When  his  arm  was  put  behind  his  back,  the 
fragment  was  reduced,  and  he  felt  relieved.  He  was  now 
laid  on  his  back,  and  nearly  a  pint  of  blood  escaped  through 
the  incision,  to  his  great  relief  Two  hours  later,  there  was 
more  bleeding  from  the  wound,  and  again  he  had  to  lie  face 
downward  to  get  any  rest.  Next  day  he  was  again  turned 
over  on  his  back,  and  a  pint  of  blood-stained  fluid  escaped. 
The  incision  remained  open  for  many  weeks.  He  finally 
made  a  complete  recovery. 

2.  A  man,  aged  2Q,  had  his  chest  crushed  in  a  railway 
accident.  He  suffered  fractured  ribs,  dyspnoea,  pain  on 
breathing,  and  cough,  and  was  cyanosed  ;  no  haemoptysis  : 
signs  of  double  hsemothorax.  Two  days  later  there  was 
marked  improvement,  and  the  blood  was  beginning  to  be 
absorbed.  By  the  twelfth  day,  the  right  side  was  everywhere 
resonant  ;  the  left  side  was  dull  below  a  line  drawn  from  the 
nipple  to  the  fifth  dorsal  spine.  On  the  nineteenth  day,  he 
was  suddenly  seized  with  severe  dyspnoea,  and  next  day  the 
whole  of  the  left  side  was  dull,  breath-sounds  feeble,  heart 
pushed  over  to  right  border  of  sternum  ;  pain  in  the  left  arm, 
oedema  of  its  upper  part  ;  thrombosis  of  the  brachial  veins. 
Three  days  later  came  oedema  and  extreme  tenderness  over 
the  left  external  jugular  vein.  He  slowly  recovered.  The 
veins  over  the  left  side  of  the  chest  were  still  dilated  when 
he  left  the  Hospital  eight  weeks  after  the  accident. 

This  sudden  effusion  on  the  nineteenth  day  cannot  have 
been  blood :  there  was  no  sign  of  profuse  internal  haemorrhage. 

'Norman,  "  Prov.  Med.  Journ.,"  1844,  vii,  29,  quoted  by 
Gurlt.     Pasrenstecher,  loc.  cit. 


FRACTURES    WITH   INTERNAL    INJURIES.         49 

It  must  have  been  due  to  thrombosis  involving  the  lelt 
innominate  vein,  probably  set  up  by  some  injury  of  the 
veins  at  or  near  the  fractured  ribs. 

Pneumothorax  may  follow  contusion  of  the  chest, 
even  though  one  cannot  find  any  clear  evidence  of  frac- 
ture. In  two  cases  lately  at  the  Metropolitan  Hospital, 
under  the  care  of  my  colleagues,  there  was  well  marked 
pneumothorax,  but  no  sign  of  fracture.  The  patients 
were  both  young  children,  who  had  been  run  over. 
They  both  made  a  rapid  recovery,  without  active  treat- 
ment.    The  following  cases  ^  illustrate  the  same  fact :- — 

1.  A  man,  aged  22,  was  admitted  to  Hospital,  having 
fallen  30  feet  :  scalp  wound,  concussion,  no  fracture  of  ribs 
or  sternum.  Next  day  it  was  found  that  the  left  side  of  the 
chest  was  hyper-resonant,  the  breath-sounds  on  this  side 
very  feeble,  the  heart  pushed  over  to  the  right  side.  Ten  days 
later,  the  hyper-resonance  was  less  marked,  and  now  there 
was  dulness  at  the  base,  and  a  well-marked  splashing  sound. 
This  sound  could  still  be  heard  four  or  five  weeks  after  the 
accident.  After  recovery,  the  left  side  remained  slightly 
contracted. 

2.  A  boy,  aged  6,  was  admitted  to  Hospital,  run  over,  but 
without  fracture.  Next  day  he  was  feverish,  and  lay  moan- 
ing, with  closed  eyes  ;  breathing  very  rapid,  and  chiefly 
abdominal.  There  was  general  hyper-resonance  of  the  left 
side  of  the  chest,  but  some  dulness  over  the  base  of  the  lung 
behind  ;  the  area  of  cardiac  dulness  was  absent,  and  the 
heart's  impulse  was  most  marked  in  the  epigastrium.  He 
made  a  good  recovery. 

In  such  cases  as  these,  the  danger  to  life  may  be  im- 
mediate, demanding  instant  treatment.  A  boy,  aged  13, 
run  over,  was  admitted  to  Hospital  with  intense  dyspnoea, 
quick  weak  pulse,  lips  blue,  skin  cold  and  livid ;  the  left 
side  of  the  chest  was  an  inch  and  a  quarter  larger  than 
the  right  side,  and  hyper-resonant ;  the  heart  was  displaced 
downward  and  to  the  right.  Puncture  was  now  made 
with  a  trochar  and  cannula  in  the  fifth  space.     Air  hissed 


'Butlin,  "St.  Bartholomew's  PIosp.  Reports,"  1875,  p.  255. 

4 


5° 


SURGERY    OF    THE    CHEST. 


out,  his  breathing  was  relieved,  his  heart  came  back  into 
place.     He  made  a  good  recovery.' 

There  is  usually  effusion  of  blood  as  well  as  of  air  into 
the  pleura  in  these  cases.  Emphysema  also  is  often 
present.  And  one  must  bear  in  mind  the  possibility  that 
a  severe  crushing  of  the  chest  may  cause  extensive  rupture 
of  the  diaphragm,  and  through  the  rent  thus  made,  the 
bowels  may  ascend  into  the  pleural  cavity,  and  by  their 
tympanitic  note  may  simulate  pneumothorax.  Such  an 
accident  is  reported  by  Larcher  ;  and  the  following  case- 
is  another  example  of  it.  A  man,  suffering  from 
severe  contusion  of  the  chest,  had  marked  hyper- 
resonance  of  the  left  side,  loss  of  vocal  vibrations,  almost 
complete  loss  of  breath  sounds,  and  displacement  of  the 
heart  over  to  the  right  side.  The  case  thus  appeared  to  be 
one  of  pneumothorax,  and  a  puncture  of  the  chest  was 
made,  but  with  no  definite  result  either  good  or  bad.  The 
patient  died  of  other  injuries  two  days  after  the  accident. 
Post  mortem,  there  was  extensive  laceration  of  the  left  half 
of  the  diaphragm  ;  and  the  stomach,  spleen,  and  trans- 
verse colon  had  ascended  into  the  left  pleural  cavity. 

Emphysema  is  not  common  in  cases  of  simple  fracture 
of  the  ribs.  Out  of  all  those  that  have  been  under 
my  care,  I  can  remember  only  a  very  few  where  emphy- 
sema was  noted  ;  nor,  if  it  does  occur,  will  it  probably 
spread  far,  last  long,  cause  pain,  or  need  treatment. 
But  of  course,  if  one  takes  only  those  cases  of  fractured 
ribs  that  are  so  serious  as  to  be  admitted  to  Hospital, 
emphysema  is  not  uncommon.  Poland  noted  it  in  19 
cases  out  of  136,  Settegast  in  3  out  of  20,  Hernia  of 
the  lung  also  may  follow  simple  fracture  of  ribs  without 
external  wound. 

'Curling,  "Med.  Times  and  Gaz.,"  1867. 
"Butlin,  "St.  Bartholomew's  Hosp.  Reports,"  1875. 


FRACTURES    WITH   INTERNAL   INJURIES.         51 

1.  A  man,  crushed  between  a  cart  and  a  wall,  suffered  frac- 
ture of  the  third,  fourth  and  fifth  right  ribs  near  the  sternum  ; 
and  this  was  followed  by  the  appearance  of  a  reducible  swell- 
ing at  the  seat  of  the  fracture.  He  lived  many  years  after  the 
accident.  After  his  death,  from  other  causes,  at  62,  the 
swelling  was  found  to  be  a  true  hernial  sac,  containing  a 
considerable  portion  of  the  lung,  wholly  unaltered. 

2.  A  man,  aged  20,  was  crushed  by  a  heavy  weight  falling 
on  him,  and  suffered  fracture  of  the  third  and  fourth  costal 
cartilages  of  one  side.  Here  a  swelling  appeared,  the  size 
of  one's  fist,  which  rose  and  fell  with  respiration  ;  there  was 
also  slight  emphysema.  He  died  three  days  after  the 
accident.  Post  viortein,  it  was  found  that  the  intercostal 
muscles  were  so  badly  torn  that  a  true  hernia  of  the  lung  had 
taken  place  through  them. 

Two  similar  cases  are  recorded  by  Wahl  and  Huguier. 

In  one,  there  was  fracture  of  the  second  and  third  ribs  ; 

the  hernia  first  occurred  some  time  after  the  accident, 

during  a  severe  fit  of  coughing :  it  was  very  tender  and 

painful.     In  time  it  receded,  leaving  a  small  hernial  ring 

about  a  third  of  an  inch  in  diameter.     In  the  other  case, 

the  fractured  rib  failed  to  unite,  and  could  be  felt  lying 

in  front  of  the  hernia,  and  moving  with  it. 

Injuries  of  the  Heart.^ 

It  is  more  correct  to  speak  of  injury  than  of  wound 
in  this  connection,  for  though  it  is  possible,  with  simple 
fracture,  for  the  heart  to  be  ruptured  by  the  violence  of 
the  accident,  or  pierced  by  a  sharp  fragment  of  rib  or 
costal  cartilage  or  sternum,  yet,  in  the  majority  of  those 
cases  that  do  not  at  once  end  in  death,  the  harm  done 
to  the  heart  is  very  slight  and  very  obscure. 

I  need  only  illustrate  injury  of  the  heart,  in  simple 
fracture,  by  the  following  cases  : — 

^  Rose,  Herz-tamponade,  "  Deutsch.  Ztschr.  f.  Chir."  xx,  1884, 
p.  329.  Heidenhain,  Ueber  die  Entstehung  von  Organischen 
Herzfehlern  durch  Quetschung  des  Herzens.  "  Deutsch.  Ztschr. 
f.  Chir.,"  1895,  ''li>  4  s-nd  5,  pp.  286 — 329. 


52 


SURGERY    OF    THE    CHEST. 


ROSE'S    CASES    OF    INJURY    OF    HEART 
("  Deutsche  Ztschr.  f.  Chir.," 

I.    With  Injury  of 


Othek  Injuries. 


Wounds  of  lip  and 
tongue.  Fracture 
of  upper  jaw. 

Fracture  of  both  clav- 
icles. 


Scalp  wound,  concus- 
sion, bruises,  frac- 
ture of  humerus. 


Scalp  wound.     Frac- 
ture of  pelvis. 


bevere  concussion. 
Compound  fracture 
of  nasal  bones. 
Lacerations  of  the 
intestines. 


Signs  and  Consequences  ok  the  Wound  of 
THE  Heart. 


The  heart  sounds  had  a  metallic  tone, 
which  lasted  two  days.  Later,  peri- 
carditis. 

Partial  pneumopericardium.  First  a 
friction  sound,  then  tympanitic  note 
over  heart,  with  metallic  ring  of 
heart-sounds.  Later,  a  rough  fric- 
tion sound  behind  the  sternum. 

Total  pneumopericardium  (total  aboli- 
tion of  cardiac  dulness,  later  tympan- 
itic note  with  metallic  splashing 
sound  synchronous  with  heart.)  Plas- 
tic pericarditis.  Adhesion  of  wound- 
ed heart  to  opening  in  pericardium. 

Heart  sounds  hardly  to  be  heard. 
Pulse  very  rapid  and  intermittent. 
Partial  pneumopericardium,  recur- 
rent. (Tympanitic  note,  cracked-pot 
sound,  metallic  ring,  synchronous 
with  heart  beat ;  metallic  heart- 
sounds,  metallic  friction  sound.) 
Pericarditis  with  effusion. 

Total  pneumopericardium  (metallic 
heart  sounds,  irregular  pulse). 
Hsemopericardium. 


Partial  pneumopericardium.  (Tympa- 
nitic note,  musical  murmur.)  Hasmo- 
pericardium.     Pericarditis. 


2.     Without  Injury 


Fracture  of  base  of 
skull,  simple  frac- 
ture of  both  femora. 
Fracture  of  left  hu- 


Pulse  very  rapid,  intermitting,  and 
irregular.  Pericarditis.  Gangrene 
in  both  lower  limbs. 


No  signs  observed,  at  the  time,  of  any 
injury  of  the  heart. 


FRACTURES    WITH   INTERNAL    INJURIES. 


53 


IN     SIMPLE     FRACTURE     OF     RIBS. 
XX.,   1884,  329 — 410.) 

Lung— 6  Cases. 


Signs  and  Consequences  of  the  Wound 
OF  THE  Lung. 


No  very  mai-ked  signs,  but    persistent 
dyspncea 

Surgical     emphysema.        Pneumoperi- 
carditis.     Pleurisy  with  effusion. 


Haemoptysis,     dyspnoea,    hsemothorax, 
pneumothorax,  surgical  emphysema. 


Haemoptysis,  orthopnoea,  contusion  of 
lung,  pneumothorax,  surgical  emphy- 
sema, pleurisy  with  effusion. 


Hsemopneumothorax.       Surgical     em- 
physema. 


Pneumopericardium.        Pleurisy     with 
effusion. 


OF  Lung — 2  Cases. 


Complications. 


Delirium  tre- 
mens (third 
attack).  Fat 
embolism  of 
lungs. 

Chronic  delir- 
ium tremens. 


Result. 


Recovery. 
Recovery. 

Death. 
Recovery. 


Death. 


Recovery. 


Double  ampu- 
tation above 
the  knees. 


Recovery. 


Death  a  year 
later  with 
pericarditis  & 
ascites. 


54  SURGERY    OF    THE    CHEST. 

These  cases  raise  a  very  important  question.  What 
are  the  ultimate  results  of  slight  injury  to  the  heart,  not 
fatal,  in  cases  of  contusion  or  simple  fracture  of  the 
chest  wall  ? 

The  best  answer  that  I  can  find  to  this  question  is 
given  in  Heidenhain's  essay  (1895)  ^^  'The  Occurrence 
of  Organic  Defects  of  the  Heart  after  Contusion.'  He 
quotes  a  great  number  of  cases,  and  draws  the  following 
conclusions  from  them  : — 

1.  There  is  evidence  to  show,  that  a  contusion, 
without  external  wound,  and  with  or  without  fracture 
of  the  ribs,  may  cause  slight  injury  of  the  walls  of  the 
heart,  which  yet  does  not  prove  fatal.  It  may  be 
supposed  that  in  such  cases  there  may  be  permanent 
impairment  of  the  action  of  the  heart. 

2.  A  contusion  may,  as  has  been  proved  by  many 
positive  observations,  cause  laceration  of  the  valves  of  the 
left  side  of  the  heart.  No  injury  of  this  kind  has  hither- 
to been  noted  on  the  right  side  of  the  heart. 

3.  From  these  lacerations  of  the  valves  of  the  heart 
by  external  violence  we  must  distinguish  that  more 
common  form  of  laceration,  which  sometimes  occurs  also 
on  the  right  side  of  the  heart,  from  internal  strain, 
through  great  increase  of  the  blood  pressure  during  very 
violent  exertion. 

4.  Lacerations  of  the  valves  can  of  themselves  only 
bring  about  impairment  of  the  action  of  the  valves. 

5.  Those  rare  cases,  in  which  a  contusion  over  the 
heart  has  been  followed  by  stenosis  of  the  valves,  can  be 
explained  only  by  later  inflammatory  changes  in  the 
valves.  So  far  as  our  knowledge  goes  at  present,  we 
must  believe  that  chronic  endocarditis  is  at  work  to  pro- 
duce them. 


53 


CHAPTER     V. 

EMPHYSEMA. 

Cases  have  already  been  given  in  which  emphysema  was 
one  among  other  troubles  ;  and  it  is  so  common,  and  some- 
times so  dangerous  to  life,  that  we  may  now  consider  it 
at  some  length.  It  has  at  all  times  held  the  attention  of 
surgeons,  and  its  conditions  and  course  have  been  made 
the  subject  of  much  experimental  work. 

As  a  rule,  it  may  be  easily  recognized,  even  when  not 
well  marked,  by  the  slight  uplifting  and  pitting  and 
increased  tension,  without  inflammation,  of  the  skin  thus 
affected,  and  by  the  strange  soft  feel  of  fine  crepitation, 
as  if  one  were  touching  a  lung,  or  a  piece  of  absorbent 
wool,  or  a  limb  affected  with  acute  gangrene.  It  is 
easily  recognized  by  this  peculiar  feel ;  but  it  is  not  very 
common.  Certainly  there  is  no  need  to  fear  it  as  Hennen 
did,  who  says,  '  When  I  first  entered  on  military  surgery, 
the  fear  of  emphysema  actually  haunted  my  hours  of 
repose.'  In  that  wonderful  monument  of  clinical  work, 
The  History  of  the  War  of  the  Rebellion,  it  was  noted 
in  38  only,  out  of  8,715  cases  of  penetrating  wound  of 
the  chest.  In  simple  fractures,  I  have  very  seldom  seen 
it,  and  have  never  seen  trouble  come  of  it.  Such  cases 
as  the  following!  must  be  rare  indeed  : — 

I.  A  boy,  aged  9,  was  run  over.  Ten  minutes  later,  on 
admission  to  Hospital,  there  was  already  general  emphysema, 

'Bastian:  "Lancet,"  i860.  Bramann:  " Verhandl.  d.  Deutsch. 
Ges.  f.  Chir."  1893,  p.  114. 


56  SURGERY    OF    THE    CHEST. 

extending  as  low  as  the  knees.  Pneumo-thorax,  marked  on 
right  side,  slight  on  left  side.  No  sign  of  any  fracture.  He 
was  restless,  with  dyspnoea,  and  rapid  feeble  pulse.  Ten 
minutes  later,  he  almost  ceased  breathing,  and  his  pulse  could 
hardly  be  felt.  Immediate  puncture  of  the  right  side  let  out 
a  great  quantity  of  air,  and  gave  him  relief;  but  he  died 
about  halt  an  hour  after  the  accident.  Post  mortem.,  no 
external  sign  of  injury,  no  collapse  of  the  lungs,  a  few  ounces 
of  blood-stained  fluid  in  the  pleurae.  'On  inflating  the  right 
lung,  we  found  a  minute  laceration  toward  the  posterior 
aspect  of  the  apex  ;  near  it,  the  second  right  rib  was  fractured 
close  to  the  tubercle,  and  a  splinter  had  cut  through  the 
pleura.' 

2.  A  man,  aged  19,  run  over,  suffered  fracture  of  third 
right  rib.  In  three  hours,  there  was  emphysema  of  head  and 
neck,  trunk,  and  upper  limbs.  In  the  course  of  the  next  few 
hours,  it  increased  enormously,  so  that  the  whole  body  was 
blown  up  like  an  air-ball ;  face  dusky  and  featureless,  eyes 
closed,  eyelids  hugely  swollen.  That  evening,  the  emphysema 
had  reached  his  feet.  He  suffered  dyspnoea,  oppression,  and 
restlessness  ;  face  cyanosed,  pulse  rapid  and  feeble,  respira- 
tion 54.  He  was  plainly  in  imminent  danger  of  death.  At 
the  seat  of  fracture,  one  could  hear  a  whistling  sound,  as  of 
air  passing  through  a  narrow  opening.  The  surgeon  now 
incised  the  chest  and  resected  two  inches  of  the  fourth  rib 
and  opened  the  pleura.  A  quantity  of  air  whistled  out. 
The  lung  was  collapsed.  Air  could  be  heard  issuing  from  it 
at  each  inspiration,  but  no  wound  could  be  seen,  and  he  was 
not  in  a  state  that  allowed  prolonged  examination.  A  valvular 
tube  was  inserted,  and  the  emphysema  became  less.  Next 
day,  it  was  worse  again,  and  the  tube,  having  become  blocked, 
was  replaced  by  a  syphon-tube.  The  emphysema  was  all 
gone  in  a  week  ;  the  tube  was  left  out  on  the  tenth  day.  He 
made  a  good  recovery. 

But  even  a  less  'fulminating'  attack  of  emphysema 
may  cause  grave  distress. ^ 

I.  A  man,  aged  66,  fell  and  broke  the  fourth  and  fifth 
right  ribs  in  the  axillary  line.  He  suffered  great  oppression, 
htemoptysis,  breathing  rapid  and  shallow,  slight  emphysema. 
Next  day,  the  emphysema  had  spread  over  the  shoulder  and 


^  Gurlt,  loc.  cit.  pp.  219,  241. 


EMPHYSEMA.  57 

the  whole  side  of  the  chest.  On  the  fifth  day,  as  the  emphy- 
sema, dyspnoea,  and  oppressive  feehng  of  suffocation  were 
all  worse,  an  incision  was  made  into  the  chest,  and  air  and 
blood  escaped,  to  his  great  relief.  A  valve  was  laid  over  the 
incision.     He  made  a  good  recovery. 

2.  A  man,  caught  between  two  railway  wagons,  suffered 
multiple  fractures  of  the  second  to  sixth  right  ribs.  On 
admission  to  hospital,  he  was  badly  collapsed,  and  was 
spitting  blood.  Over  the  seat  of  fracture  was  a  large 
emphysematous  swelling  rising  and  falling  with  respiration, 
and  under  such  high  pressure  that  the  emphysema  spread 
over  more  than  half  of  the  body.  Scarification  was  used 
where  it  was  worst ;  bandages  were  applied,  and  a  truss  so 
arranged  over  the  shoulder  as  to  keep  the  fragments  in 
better  apposition. 

3.  A  man,  aged  56,  was  crushed  over  the  chest,  three  ribs 
on  the  left  side  being  fractured  and  driven  far  inward  ;  the 
soft  parts  over  them  contained  air,  and  flapped  in  and  out 
with  respiration.  Emphysema  had  begun  round  the  seat  of 
injury.  He  was  bled  and  bandaged,  and  got  great  relief, 
but  only  for  a  few  hours.  The  emphysema  spread  rapidly  up 
into  the  neck,  over  the  whole  left  side,  and  down  the  arm  as 
far  as  the  elbow,  covering,  next  day,  the  whole  of  the  chest  ; 
but  here  it  stopped,  and  in  about  a  fortnight  was  wholly 
absorbed. 

In  contrast  with  these  cases,  which  recovered,  save 
one  where  death  from  shock  occurred  half  an  hour  after 
the  accident,  I  place  the  following,^  in  which  it  seems 
that  nothing  was  done  to  avert  death.  A  man,  aged  60, 
run  over,  suffered  fracture  of  the  fourth  and  fifth  left 
ribs.  General  empliysema  followed,  and  he  died,  slowly 
suffocated,  on  the  fourth  day.  Fosi  mortev^  there  was 
emphysema  of  the  whole  surface,  save  only  the  palms 
and  soles.  The  opening  into  the  pleural  cavity  was  so 
small  as  to  be  only  just  visible.  There  was  a  very  small 
superficial  laceration  of  the  lung,  but  no  blood  in  the 
pleural  cavity. 


•Boyer,  "Traite  des  Maladies  Chirurgicales,"  vii,  286. 


58  SURGERY    OF    THE    CHEST. 

These  six  cases  illustrate  the  occurrence  ot  severe  em- 
physema after  a  simple  fracture  of  the  ribs.  As  to  its 
relation  to  penetrating  or  gunshot  wounds  of  the  chest, 
one  thing  is  certain  :  that  it  is  not  common,  and  is,  on 
the  whole,  more  likely  to  follow  a  wound  with  a  knife  or 
a  bayonet  than  a  gunshot  wound  :  either  the  former  is 
more  often  valvular,  or  the  latter  bruises  the  air-vesicles 
and  bronchioles,  and  thus  prevents  the  escape  of  air. 
Most  authorities  are  agreed  as  to  the  rarity  of  emphysema 
after  gunshot  wounds.  In  the  American  War,  it  was 
noted  in  only  38  out  of  8715  cases  of  penetrating  wound 
of  the  chest.  'The  plain  fact  is,  that  it  does  not  occur  in 
one  case  in  fifty'  (Hennen).  'According  to  observations 
made  in  the  wars  of  the  last  twenty  years,  it  appears  to 
follow  injuries  of  the  chest  in  only  one  out  of  two 
hundred  cases'  (Neudorfer).  There  is  no  need  to  quote 
many  cases  of  emphysema  in  penetrating  wound  of  the 
chest ;  but  mention  must  be  made  of  the  celebrated 
case  published  by  Larrey.i 

A  younij  soldier  received  a  sword-thrust  through  the 
fourth  right  intercostal  space.  In  a  few  hours,  there  was 
general  emphysema.  '  So  severe  was  it,  that  all  the  promi- 
nences and  hollows  of  the  surface  of  the  body  were  almost 
obHterated  ;  he  had  become  a  mere  tense,  inflated,  reso- 
nant, crepitant  mass.'  His  neck  was  so  swollen  that  his 
head  seemed  continuous  with  his  shoulders.  Mouth,  nos- 
trils, and  eyes  were  closed  up.  The  scrotum  was  the  size  of 
a  child's  head  ;  he  suffered  frightful  pain  and  dyspncea. 
Larrey  at  once  applied  firm  pressure  over  the  wound,  and 
made  two  incisions,  one  near  the  trachea  to  relieve  pressure 
liere,  and  one  over  the  sternum.  He  also  cupped  him 
repeatedly,  both  over  the  incisions  and  elsewhere.  In  two 
hours  he  was  much  relieved.  Next  day,  the  cupping  was 
repeated.     He  made  a  good  recovery. 

It  is  evident  that  for  the  production  of  severe  emphy- 
'"Clinique  Chirurgicale,"  1832,  ii,  195. 


EMPHYSEMA.  59 

sema,^  the  lung  must  be  neither  inactive  nor  collapsed, 
the  wound  in  it  small,  and  the  whole  injury  such  that 
the  air  can  be  forced  far  and  wide  by  each  stroke  of  the 
lungs,  into  the  loose  areolar  tissue.  The  size  of  the 
wound  of  the  lung  is,  indeed,  in  inverse  proportion  to 
the  extent  of  the  emphysema.  A  specimen  in  the 
College  of  Surgeons'  Museum,  from  a  case  of  fatal 
emphysema,  shows  a  sort  of  pin-prick  in  the  lung,  only 
just  admitting  a  bristle.  Dr.  Ewart-  records  a  case 
where  puncture  of  the  lung  with  a  trochar,  only  t^.,-  inch 
in  internal  measurement,  in  search  of  pus,  was  followed 
l)y  fatal  pneumothorax ;  and  in  such  a  case,  where 
pneumothorax  is,  emphysema  may  be.  Dr.  Theodore 
Williams^  records  a  case  where  simple  puncture  of  a 
tubercular  cavity  was  followed  both  by  pneumothorax 
and  emphysema.  Dr.  West*  records  a  case  where  aspira- 
tion of  pneumothorax  was  followed  by  emphysema  of 
the  whole  side  of  the  chest. 

Though  most  authorities  are  agreed  that  extensive 
emphysema  is  more  often  talked  about  than  seen,  others 
declare  it  to  be  common.  Larrey  said  that  the 
majority  of  penetrating  wounds  of  the  chest  are  followed 
by  more  or  less  emphysema.  And  in  our  war  with 
the  Maoris,    out   of    twenty-three    penetrating    wounds 


'  For  a  full  understanding  of  the  causes  and  treatment  of 
emphysema,  we  have,  as  our  guides.  The  History  of  the  War  of 
the  Rebellion,  the  monographs  by  Dr  Champneys  in  volume 
i.xviii  of  the  Medico-Chirurgical  Society's  Transactions,  and 
Bramann's  paper  on  the  treatment  of  general  emphysema,  in  the 
Transactions  of  the  German  Surgical  Association  for  1S93.  To 
the  teaching  of  these  authorities  I  add  some  scattered  notes  from 
other  sources. 

^  "Medical  Society's  Trans.,"  1890,  xiii,  56. 

3  See  True,  "Chirurgie  du  Poumon,"  1885. 

'•  "Clinical  Society's  Transactions,"  1S84,  xvii,  56. 


6o  SURGERY    OF    THE    CHEST. 

carefully  noted,  emphysema  occurred  in  six.  Still,  the 
weight  of  authority  is  against  Larrey.  Severe  emphy- 
sema is  rare  because,  in  most  wounds  of  the  lung,  the 
conditions  for  a  perfect  valve  are  absent,  or  the  lung  is 
bruised  or  lacerated,  not  clean  cut ;  or  it  is  collapsed;  or 
the  pressure  of  air  or  of  blood  in  the  pleural  cavity  prevents 
the  escape  of  air.  Again,  a  very  small  wound  of  the 
lung,  such  as  would  be  most  likely  to  cause  emphysema, 
is  rapidly  sealed  over,  unless  it  is  held  open  by  old  pleural 
adhesions.  Konig,^  from  numerous  experiments,  found 
that  even  the  removal  of  large  pieces  of  the  lung,  without 
subsequent  suturing  of  the  gap,  was  not  enough  to  cause 
severe  emphysema.  In  a  couple  of  hours  the  lung  was 
sealed  over  and  began  to  expand  again,  and  the  air  that 
had  escaped  under  the  skin  began  to  be  absorbed.  He 
is  of  opinion  that  no  usual  form  of  wound  of  the  lung, 
either  accidental  or  experimental,  can  produce  general 
emphysema,  unless,  at  the  place  where  it  is  inflicted, 
there  are  old  adhesions  between  the  lung  and  the  pleura; 
and  he  has  been  able  to  assure  himself  of  the  presence 
of  these  adhesions  in  more  than  one  post  mortem  exam- 
ination. 

A  further  reason  against  the  wide  extension  of  emphy- 
sema lies  in  the  resistance  of  all  living  tissues  to  invasion. 
Air  under  the  skin  is  an  irritant,  a  foreign  body.  It  is 
easy  to  drive  air  under  the  skin  of  a  dead  animal,  but 
living  areolar  tissue  can  to  some  extent  defend  itself,  as 
we  see  when  blood  is  effused  under  the  scalp,  or  urine 
into  the  perinaeum.  With  each  stroke  of  the  lungs, 
moreover,  the  pressure  must  be  exercised  over  an  increased 
body  of  air,  and  become  weaker  at  any  one  point ;  the 
advance  of  the  whole  mass  of  air  must  be  slower,  and 

^ See  discussion  on  Bramann's  paper,  loc.  cit. 


EMPHYSEMA.  6i 

more  easily  resisted.  It  is  suggested  by  Dr.  Champneys, 
that  general  emphysema  occurs  only  in  those  whose 
areolar  tissue  is  especially  loose,  or  unable  to  withstand 
the  invasion  that  has  suddenly  assailed  it. 

It  is  certain  that  emphysema  does  occur  without 
pneumothorax;  and  that  it  is  not  of  itself  proof  that  the 
lung  has  been  wounded,  (i)  Slight  emphysema  may 
follow  a  non-penetrating  irregular  wound  of  the  soft  parts, 
the  outside  air  being  drawn  by  the  movements  of  respi- 
ration into  the  loose  areolar  tissue;  this  has  been  observed 
in  wounds  opening  the  axilla.  (2)  Emphysema  without 
pneumothorax  may  be  due  to  old  adhesions  at  the  seat 
of  injury,  between  the  lung  and  the  pleura.  (3) 
Emphysema  may  be  due  to  an  extra-pleural  laceration  at 
or  near  the  root  of  the  lung,  whence  the  air  passes  into 
the  anterior  mediastinum,  up  into  the  neck  beneath  the 
deep  cervical  fascia,  and  so  reaches  other  parts  of  the 
body. 

In  those  rare  cases  of  very  extensive  emphysema, 
without  pneumothorax,  where  careful  post  7nortem  exam- 
ination has  failed  to  find  any  evidence  that  the  surface  of 
the  lung  was  wounded,  this  third  explanation  is  the  only 
one  possible.  The  occurrence  of  laceration  at  the  root 
of  the  lung  would  be  favoured  by  extreme  tension  (deep 
inspiration)  at  the  moment  of  the  accident.  And  Dr. 
Champneys  has  proved,  by  a  very  important  series  of 
experiments  on  the  dead  body,  that  in  life  the  anterior 
aspect  of  the  root  of  the  lung  is  just  the  part  that  is 
least  able  to  withstand  increase  of  the  internal  pressure. 

It  is  this  form  of  emphysema  that  may  occur  during 
the  pains  of  labour  :  but  it  is  not  likely  to  extend  far. 
The  following  case  may  be  worthy  of  note  : — 

A  primipara,  aged  22,  toward  the  end  of  her  labour,  ex- 
claimed that  she  could  not  ooen  her  eyes  or  breathe,  and  did 


62  SURGERY    OF    THE    CHEST. 

not  know  what  had  come  over  her.  '  Her  face  was  very 
much  swollen  :  it  pitted  deeply,  and  crepitated  on  pressure. 
Her  neck  was  puffed  up  to  double  its  natural  size,  and  the 
skin  covering  her  chest  became  a  completely  and  rather 
tightly  filled  bag  of  air.  However,  labour  went  on,  and 
about  two  hours  later  she  was  delivered  of  a  healthy  child.' 
A  fortnight  later,  the  emphysema  had  all  disappeared, 
except  a  trace  of  it  on  the  right  side  of  the  face.'  ' 

The  terrible  oppression,  dyspnoea,  and  prostration, 
which  occurred  in  some  of  the  above  cases,  were  plainly 
due  to  the  pneumothorax,  not  to  the  mere  presence  of 
air  under  the  skin.  But  there  is  one  result  of  emphysema, 
noted  by  Litten,-  which  is  of  interest.  He  found 
on  repeated  occasions,  in  cases  of  emphysema  from 
various  causes,  that  the  urine  contained  crystals  of  calcium 
phosphate,  of  a  peculiar  wedge-like  shape,  grouped 
together  by  their  pointed  ends ;  and  he  was  able  to 
produce  these  by  inducing  emphysema  of  the  skin  of 
rabbits.  The  formation  of  these  crystals  does  not 
depend  on  the  character  of  the  gas  used  for  producing 
the  emphysema ;  and  the  same  crystals  have  been 
noted  in  the  old  varnishing  experiments.  They  must, 
therefore,  be  due  to  some  loss  of  function  of  the  emphy- 
sematous skin. 

Finally,  we  come  to  the  treatment  of  emphysema. 
Two  things  are  certain  :  first,  that  emphysema  tends  to 
get  well  of  itself ;  next,  that  the  danger  of  death  is  not  so 
much  in  the  emphysema,  as  in  the  pneumothorax  with 
which  it  is  associated.     Still,  if  the  emphysema  is  of  great 


'Pratt,  "  Dublin  Quarterly  Journal,"  1864,  xxxviii,  249.  Similar 
cases,  but  not  quite  so  severe,  are  given  by  Morel-Lavallee,  "  Bull. 
Sec.  de  Chir,"  1847,  p.  89.  Riedinger  quotes  the  case  of  a 
cornet-player,  who  habitually,  when  he  played  hard,  had  a 
transient  attack  of  emphysema  of  the  hypogastric,  inguinal,  and 
scrotal  regions. 

^  "  Verhandl.  d.  Congress  f.  Inn.  Med."  1885-86,  p.  417. 


EMPHYSEMA .  63 

tension,  causing  distress  and  sharp  pain,  something  must 
be  done,  and  two  or  three  short  incisions  are  better  than 
a  large  number  of  small  punctures.  Tight  bandaging 
is  unbearable ;  ice  to  the  wound  is  useless.  The  relief 
of  the  pneumothorax  will  be  considered  in  the  next 
chapter. 


64 


CHAPTER    VI. 

PNEUMOTHORAX. 

VVe  come  now  to  ground  that  belongs  rather  to  medicine 
than  to  surgery,  not  only  because  any  destructive  disease 
of  the  lung  may  be  the  cause  of  pneumothorax,  but  also 
because  there  are  many  problems  in  pneumothorax — 
mechanical,  chemical,  and  physiological — as  to  intra- 
pleural pressure,  absorption  of  gases,  tension  of  the 
lungs,  and  so  forth,  which  do  not  belong  to  surgery. 
He  who  would  study  the  scientific  aspects  of  pneumo- 
thorax, must  go  to  the  writings  of  Dr.  West,  Dr.  Ewart, 
and  Dr.  Douglas  Powell.  Here,  we  are  concerned 
only  with  its  surgical  side. 

We  may  therefore  begin  with  cases  ^  of  pneumothorax 
due  to  disease,  but  in  need  of  surgical  treatment. 

1.  A  gu-1  of  15,  with  tubercular  phthisis,  was  admitted  to 
Hospital  on  the  25th  of  May.  On  the  4th  of  July,  early  in  the 
morning,  she  awoke  shrieking  with  pain  in  the  lett  side. 
Her  face  was  pale  and  sunken  ;  pulse  140,  respiration  36. 
The  heart  was  beating  under  the  right  nipple,  evidently 
displaced  by  pneumothorax  of  the  left  side.  The  chest  was 
at  once  punctured  with  a  fine  trochar  and  cannula,  and  air  was 
let  out,  but  in  no  great  quantity.  She  had  no  return  of  her 
acute  distress,  and  died  ten  days  later.  Post  mor/ejn,  a 
tubercular  cavity  in  the  upper  lobe  o  the  lung  had  opened 
into  the  pleura. 

2.  A  man,  aged  41,  was  admitted  to  Hospital  with  tuber- 
cular phthisis,  and  pneumothorax  of  die  left  side.  Two 
days  after  admission  he  was  seized  with  dyspnoea,  and  his 
distress  became  so  great  that  a  puncture  was  made  into  the 
left  side  of  the  chest ;  a  large  quantity  of  air  escaped,  mixed 

'  Cayley,  "Clin.  Soc.  Trans.,"  xvii.,  p.  52;  Ewart,  "Med.  Sec. 
Trans.,"  xiii.,  p.  56;  Andrew,  "St.  Bart.  Hosp.  Reports,"  xiii.,  p. 
215- 


PNEUMOTHORAX.  65 

»vith  a  little  non-offensive  pus.  He  gained  great  relief,  but 
died  suddenly  three  days  later.  Fosi  7nortem,  there  were 
found  tubercular  cavities  in  both  lungs.  The  left  pleura  was 
much  thickened,  and  contained  air,  and  about  a  quart  of  pus. 
The  lung  was  collapsed  ;  on  its  posterior  aspect,  close  to 
the  root,  and  a  little  above  it,  was  a  small  perforation  leading 
into  a  cavity. 

3.  A  man,  aged  35,  was  admitted  to  Hospital  with  tuber- 
cular phthisis,  and  pneumothorax  of  the  left  side.  He  was 
suffering  from  dyspnoea,  and  unable  to  lie  down  ;  the  heart 
was  displaced  to  the  right  side.  The  dyspnoea  had  come  on 
so  gradually  that  he  could  not  give  the  date  when  it  began. 
Three  days  after  admission,  having  suffered  restless  nights 
with  fever,  delirium,  and  absolute  inability  to  rest  lying  down 
he  was  aspirated,  and  gained  considerable  relief.  The  heart 
came  back  part  of  the  way  to  its  normal  position.  But  next 
day  it  was  again  displaced  ;  and  the  following  day  he  died. 
Post  tnortem,  the  left  pleura  was  distended  v^^ith  air,  and  con- 
tained a  little  clear  fluid.  The  left  half  of  the  diaphragm  was 
much  displaced  downward  ;  the  lung  was  collapsed.  A 
narrow  sinus  was  found,  tracking  through  adhesions,  opening 
into  the  pleura  from  a  cavity  in  the  lung. 

4.  A  man,  aged  24,  after  some  weeks  of  attendance  as  an 
out-patient  with  symptoms  of  phthisis,  was  suddenly  seized 
one  evening  with  severe  pain  in  the  right  side,  and  dyspnoea. 
He  was  admitted  to  Hospital  at  once,  and  next  day  a  large 
quantity  of  air  was  drawn  off  with  the  aspirator.  This  air, 
or  rather  gas,  was  found  to  extinguish  a  lighted  taper  at 
once,  but  contained  no  large  excess  of  carbonic  acid  as  com- 
pared with  atmospheric  air.  He  was  relieved,  and  refused 
to  stay  in  Hospital.  Four  days  later,  he  was  again  admitted, 
with  some  air  still  in  the  pleura,  and  a  good  deal  of  emphy- 
sema, extending  as  low  as  the  right  inguinal  region.  The 
whole  mass  of  air,  both  in  the  pleura  and  under  the  skin,  was 
absorbed  (without  pleural  effusion)  in  about  six  weeks. 
More  than  a  year  later,  the  signs  of  phthisis  were  still  in 
abeyance,  save  for  a  very  slight  hsemoptysis,  and  he  was  in 
his  usual  health,  and  not  losing  flesh. 

5.  A  girl,  aged  14,  was  admitted  to  Hospital  with  typhoid 
fever.  The  case  was  a  very  serious  one,  with  delirium,  high 
fever,  albuminuria,  and  bronchitis.  On  the  9th  of  May,  she 
complainerl  of  severe  pain  in  the  right  side  ot  the  chest  ;  on 
the  nth  thei^e  were  pain,  tenderness,  and  a  friction-sound 
with  fine  crepitant  rales  ;  on  the  13th  she  had  a  serious 
attack  of  dyspnoea,  with  prostration  ;    on  the  15th  the  signs 

5 


66  SURGERY    OF    THE    CHEST. 

of  pneumothorax  were  well  marked  ;  on  the  i6th  she  had 
intense  dyspnoea,  and  seemed  to  be  dying ;  and  on 
the  i8th  had  a  similar  attack.  After  this,  she  began  to  im- 
prove, but  the  pneumothorax  remained  unabsorbed  ;  on  the 
25th,  therefore,  her  side  was  punctured,  and  a  quantity  of  air 
was  let  out.  '  This  gave  considerable  relief  to  the  dyspnoea, 
but  produced  no  alteration  in  the  physical  signs.'  A  second 
puncture  was  made  two  days  after  the  first.  A  fortnight 
later,  the  pneumothorax  was  all  absorbed,  and  she  was 
convalescent. 

These  instances  clearly  show  the  surgical  aspect  of 
some  cases  of  pneumothorax  from  disease.  Among  the 
diseases  giving  rise  to  it,  tubercular  phthisis  is  by  far  the 
most  common  ;  indeed.  West  says  nine  cases  out  of  ten 
are  due  to  it.^  Other  causes,  apart  from  wounds  of  the 
lung,  are  the  rupture  of  an  emphysematous  vesicle  on 
sudden  exertion  or  violent  coughing,  the  breaking  of  an 
empyema  into  a  bronchus,  and  advanced  abscess  or 
gangrene  of  the  lung.  A  few  cases  also  seem  to  show 
that  a  severe  strain  may  cause  slight  laceration  of  the 
surface  of  the  lung  and  pneumothorax,  even  "though 
the  lung  be  healthy,  or,  at  all  events,  free  from  any  active 
disease.  Case  4,  of  pneumothorax  in  typhoid  fever, 
'  was  probably  due  to  the  breaking-down  of  a  pulmonary 
embolism,  from  thrombosis  of  the  right  cavities  of  the 
heart.'  A  similar  state  of  the  heart  is  shown  by  Dr. 
Drewitt  to  explain  the  occurrence  of  gangrene  of  the 
lower  hmbs  in  certain  cases  of  typhoid. 

It  is  to  be  noted  that  pneumothorax  is  absent  in  those 
curious  cases  in  which  a  sharp  foreign  body,  such  as  a 
head  of  grass  or  a  stalk  of  corn,  swallowed  or  drawn  into 
the  air-passages,  has  very  slowly  worked  its  way  out 
through  one  of  the  intercostal  spaces.      Two  such  cases 

^  Habershon  notes  that  out  of  1,375  post-mortem  examinations 
of  cases  of  phthisis  (Brompton  Hospital,  1885 — 1896),  pneumo- 
thorax had  occurred  in  114,  about  8  per  cent. — The  Hospital, 
April  nth,  1896. 


PNE  UMO  THORA  X.  67 

are  published  by  Mr.  Godlee^ :  in  one,  a  head  of  grass, 
forty-three  days  after  it  had  been  swallowed,  escaped 
through  the  sixth  left  intercostal  space,  three  inches  from 
the  spine  ;  in  the  other,  a  similar  piece  of  grass,  fourteen 
days  after  it  had  been  swallowed,  escaped  through  the 
ninth  left  space  near  the  angles  of  the  ribs ;  it  had  a  distinct 
faecal  odour.  But  in  cases  like  these,  if  cough,  haemopty- 
sis, pleurisy,  and  pneumothorax  are  absent,  it  is  probable 
that  the  foreign  body  has  not  really  traversed  the  lung. 

As  regards  the  treatment  of  pneumothorax  arising  from 
disease  of  the  lung,  it  should  be  noted  that  often  its  onset 
is  not  so  sudden,  and  its  consequences  not  so  serious,  as 
in  some  of  the  cases  quoted.  '  In  some — latent  pneumo- 
thorax— the  initial  symptoms  are  slight,  or  even  entirely 
absent.  To  a  bed-ridden  patient,  with  advanced  phthisis, 
it  matters  little  whether  a  lung  be  useless  on  account  of 
phthisis,  or  because  of  the  collapse  of  the  lung  which 
results  from  the  pneumothorax."  Again,  many  cases 
have  been  recorded  where  in  a  short  time  the  air  was 
all  absorbed,  and  the  lung  restored  to  its  full  strength. 
*  Fluid  follows  the  pneumothorax  ;  the  air  is  absorbed, 
and  the  case  becomes  converted  into  one  of  pleuritic 
effusion,  from  which  recovery  may  take  place  in  the  usual 
way ' ;  or  the  air  may  be  absorbed  even  without  effusion 
of  fluid."     Again,  it  is  useless  to  draw  air  from  the  pleura 

'  "  Clin.  Soc.  Trans.,"  xv.,  p.  156.  Dr.  Good  ("  St.  Bart.  Hosp. 
Rep.,"  1891)  gives  the  case  of  a  child,  aged  5,  where  the  grass 
escaped  three  inches  below  the  axilla :  it  caused  some  suppuration 
within  the  chest,  with  coughing  up  of  pus,  but  no  pneumothorax. 

^  See  a  case  published  by  Dr.  West,  "Clin.  Soc.  Trans.,"  1884, 
xvii.,  p.  56,  with  a  collection  of  23  similar  cases.  The  causes  of 
the  pneumothorax,  given  in  18  of  the  24,  were  as  follows : 
phthisis,  4 ;  probably  phthisis,  4  ;  rupture  of  emphysematous 
vesicle,  5  (not  all  certain) ;  over-exertion,  2  ;  external  injury,  3. 
Out  of  15  of  the  24,  in  which  the  sex  of  the  patient  was  given, 
only  I  was  a  woman. 


68     ■  SURGERY    OF    THE    CHEST. 

till  the  opening  in  the  lung  is  soundly  healed.  And  it 
is  possible  that  a  too  vigorous  use  of  the  aspirator  might 
even  re-open  a  healed  spot  in  the  lung,  or  excite  latent 
mischief  to  become  active.  Finally,  there  is  reason  to 
believe  that  in  some  cases  of  tubercular  phthisis,  with 
slight  effusion,  the  presence  of  this  moderate  amount  of 
air  or  fluid  tends  to  check  the  advance  of  the  disease. 

Thus  the  need  for  surgery  in  cases  of  pneumothorax 
from  disease  is  not  so  evident  as  may  at  first  sight  appear. 
But  if  we  cannot  hope  to  do  much  good  in  advanced 
phthisis,  yet  in  a  case  of  rapid  oppressive  pneumothorax 
from  any  cause  we  may  give  great  relief  and  may  even 
avert  death.  We  cannot  determine  how  long  the  lung 
will  hold  out  before  it  collapses  under  the  pressure  of 
the  effused  air ;  we  cannot  be  sure  that  some  sudden  fit 
of  coughing,  or  straining  during  evacuation  of  the  bowels, 
may  not  pour  a  further  quantity  of  air  into  the  pleura, 
and  bring  the  patient  into  immediate  danger  of  dying. 
The  perforation  in  the  lung  is,  in  many  cases,  minute, 
valvular,  and  soon  healed.  The  puncture  is  in  itself  a 
very  small  thing,  and  of  course  no  anaesthetic  should  be 
given.  Except  for  one  case  where  it  was  followed  by 
emphysema,  I  can  find  no  evidence  that  it  can  do  harm  : 
and  a  simple  trochar  and  cannula  may  do  as  well  as 
an  aspirator. 

'  For  the  relief  of  the  dyspnoea  iiiimediately  after  the 
onset  of  pneumothorax,  aspiration  would  seem  to  hold 
out  but  a  slender  chance  of  usefulness  ;  it  is  hardly 
possible  that  within  a  delay  of  a  few  hours  any  notable 
change  should  have  taken  place  in  the  abnormal  passage 
and  orifice.  Nevertheless,  in  some  cases,  the  attendant 
circumstances  may  have  become  less  unfavourable,  as, 
for  instance,  where  severe  strain  was  the  immediate 
cause  of  the  accident If  the  patient  should 


PNEUMOTHORAX.  69 

experience  no  relief;  if  no  decided  return  of  the  heart 
can  be  made  out ;  if,  while  the  air  pump  is  being  used, 
the  stethoscope,  appHed  to  the  upper  part  of  the  chest, 
should  transmit  to  the  ear  a  loud  sound  of  in-rushing  air, 
the  operation  may  be  abandoned  as  useless,  and  not  be 

renewed  for  a  long  time,  if  at  all In  every  case 

it  should  be  followed  by  absolute  rest,  and  by  every 
available  means  for  the  avoidance  of  cough.' 

With  regard  to  these  rules  given  by  Dr.  Ewart,'  the 
first  and  fourth  of  the  cases  that  I  have  quoted  show  that 
puncture,  even  a  very  few  hours  after  the  onset  of  the 
pneumothorax,  may  yet  not  be  in  vain.  And  the  de- 
ficiency of  oxygen  in  the  gas  withdrawn  in  the  fourth  case 
gives  us  another  test,  in  addition  to  those  given  by 
him,  by  which  we  may  judge  whether  the  perforation  in 
the  lung  is  closed  or  open. 

I  think  that  if  one  reads  the  literature  of  pneumo- 
thorax due  to  disease,  he  will  come  to  the  opinion  that  a 
good  many  cases  are  recorded  in  which  puncture  was 
either  neglected  altogether,  or  postponed  when  it  ought 
to  have  been  done  early. 

As  regards  pneumothorax  due  to  external  injury,  what 
may  be  called  surgical  pneumothorax,  we  must  note  that 
the  injury  may  be  inflicted  by  the  surgeon  himself,  as  in 
the  following  2  cases. 

I.  A  man,  aged  34,  admitted  to  Hospital  with  peripheral 
neuritis  from  drink,  during  his  convalescence  became  fever- 
ish, and  showed  signs  which  seemed  to  indicate  a  left  pleural 
effusion.  The  chest  was  therefore  punctured  in  the  sixth 
space,  but  no  fluid  was  found.  In  a  few  minutes  he  was 
seized  with  dyspnoea,  became  cyanosed,  and  was  found  to 

^  "On  Pneumothorax,  and  the  value  of  its  treatment  by  aspira- 
don."     Med.  Soc.  Trans.,  xiii.,  p.  56. 

=  Billroth,  "Clinical  Surgery"  (Syd.  Soc.  Trans.),  p.  192; 
Ewart,  loc.  cit. 


yo  SURGERY    OF    THE    CHEST. 

have  pneumothorax.  He  was  unable  to  rest  lying  down. 
He  continued  for  some  days  subject  to  more  or  less  pain  and 
dyspnoea  ;  but  as  the  displacement  of  the  heart  seemed  to  be 
less  marked  than  at  first,  no  surgical  treatment  was  adopted. 
On  the  sixth  day  after  the  accident  he  died  suddenly,  in  an 
attack  of  intense  dyspnoea.  Fos^  nio7-teni.,  the  pleura  con- 
tained air,  and  a  small  quantity  of  blood-stained  fluid.  The 
lung  was  collapsed,  the  puncture  in  it  was  healed. 

2.  A  man  was  admitted  to  Hospital  with  fracture  of  the 
fourth,  fifth  and  sixth  right  ribs  ;  the  skin  was  strained  tight 
over  one  of  the  fragments,  and  gradually  a  small  patch  of 
skin  at  this  place  became  gangrenous.  On  the  seventeenth 
day  a  sharp  point  of  bone  came  through  the  skin,  and  an  at- 
tempt was  made  to  remove  it  with  the  forceps.  At  this 
moment  air  was  heard  to  pour  into  the  pleura,  and  pneumo- 
thorax was  at  once  evident.  It  was  followed  by  pleural 
effusion.  The  lacerated  skin  became  the  starting-point  of 
erysipelas,  and  of  this  the  patient  died  twenty-two  days  after 
the  onset  of  pneumothorax. 

These  two  cases  are  of  great  interest :  the  first  es- 
pecially is  strong  evidence  of  what  I  have  already  urged, 
that  one  ought  not  to  delay  puncture  of  a  severe  pneumo- 
thorax unless  there  is  some  clear  reason  against  it. 

So  many  cases  of  pneumothorax  from  injury — con- 
tusion of  the  chest,  fracture  of  the  ribs,  penetrating 
wound  of  the  chest — have  already  been  given  in  the 
chapters  on  these  subjects  that  I  need  not  quote  more. 
Its  treatment  in  these  cases,  if  it  need  to  be  treated,  is 
on  the  lines  already  laid  down.  It  remains  for  us  to 
consider  some  general  facts  as  to  the  character  and 
course  of  pneumothorax,  such  as  are  not  outside  the 
range  of  this  book. 

An  excellent  account  of  it  is  given  by  Frantzel.'  He 
refutes  the  old  theories  that  air  can  transude  through  a 
healthy  lung  into  the  pleura,  or  that  pus  free  in  the 
pleural  cavity,  as  in  empyema,  can  of  itself  evolve  gases 

'  "  Ziemssen's  Flandbuch.,"  1875. 


PNEUMOTHORAX.  -jt 

to  fill  the  pleura.  According  to  his  own  experience, 
phthisis  is  the  cause  of  it  in  14  cases  out  of  15  ; 
and  Saussier's  figures^  put  the  percentage  of  phthisical 
patients  too  low.  The  phthisis  most  apt  to  cause  it 
is  rapid  in  its  course,  not  favourable  to  the  formation 
of  adhesions.  In  many  cases  {e.g.,  in  advanced  phthisis) 
pneumothorax  may  occur  without  any  marked  dyspnoea, 
and  the  patient  may  not  be  conscious  of  it.  But,  as 
a  rule,  he  feels  that  '  something  has  given  way '  in  his 
chest,  or  may  be  sensible  of  the  current  of  air  blowing 
into  his  pleura  ;  he  has  pain  and  shortness  of  breath, 
and  is  cyanosed  ;  and  even  in  the  first  few  days  there 
may  be  noted  oedema  of  the  face  and  of  the  extremities. 
The  gravity  of  the  shock  and  of  the  dyspnoea  may  be  so 
severe  that  the  patient  dies  in  a  few  days,  or  even  hours. 
It  is  rare  to  find  only  air  in  the  pleura  ^  :  a  secondary 
pleurisy  usually  in  a  few  days  follows  the  onset 
of  the  pneumothorax :  this  effusion  is  of  a  sero-purulent 
character,  and  may  be  attributed  to  infection  either  from 
the  disease  of  the  lung,  or  from  the  air  in  the  pleura. 

As  to  the  symptoms  and  physical  signs  of  pneumothorax, 
pain  is  not  common,  save  at  the  onset ;  cough  is  variable  ; 
and  the  circulation  is  obstructed,  so  that  there  may  be 
some  duskiness  of  the  face,  oedema,  and  scanty  albumin- 
ous urine.  The  fulness  of  the  intercostal  spaces,  and  the 
displacement  of  the  heart,  may  be  even  more  marked  in 
pneumothorax  than  in  fluid  effusions.  There  is  no  fever  ; 
indeed,  the  sudden  onset  of  pneumothorax  may  depress 
the  temperature  to  97°  or  lower ;  and  this  is  a  bad  sign, 
especially  if  the  pulse  be  very  rapid.  The  pulse  is  rapid, 
small,   of  low  tension,   the  respiration  rapid  and  often 

^  Saussier,  in  131  cases,  assigns  only  81  to  phthisis. 
^  Out  of  147  cases  of  pneumothorax,  collected  by  Monneret  and 
Fleury,  there  were  only  16  where  there  was  no  fluid  effusion. 


7'^ 


SURGERY    OF    THE    CHEST. 


difficult ;  but  in  patients  with  advanced  phthisis  the  res- 
piratory centres  are  so  enfeebled  and  ill-nourished  that 
they  do  not  much  resent  the  loss  of  oxygen.  It  is  the 
strongest  patients,  least  accustomed  to  do  with  only  one 
lung,  who  are  in  most  danger ;  and  in  old  phthisical 
patients  one  may  be  led  to  suspect  pneumothorax,  not 
from  any  complaint  on  their  part,  but  merely  from  a 
change  in  the  pulse,  or  in  the  position  taken  in  bed.^ 

To  this  abstract  of  Frantzel's  teaching  we  must  add 
some  consideration  of  the  question  why  so  many  pene- 
trating wounds  of  the  chest  occur  without  pneumo- 
thorax. During  the  American  Civil  War,^  it  was  the 
general  experience  that  traumatic  pneumothorax  very 
rarely  assumed  such  a  phase  as  to  excite  alarm.  In  the 
vast  series  of  chest-wounds  (11,549  gunshot  wounds 
alone,  beside  incised  and  punctured  wounds)  this  com- 
plication is  noted  as  troublesome  in  less  than  half-a- 
dozen.  Indeed,  the  very  opposite  may  happen,  and  the 
naked  lung  may  come  out  through  the  wound,  forming  a 
hernia  of  the  lung.  So  far  back  as  1809,  P.  J.  Roux  •'' 
proved  by  experiment  that  a  penetrating  wound  is  not 
necessarily  followed  by  pneumothorax.  '  One  may  see 
the  lung  moving  freely  in  respiration,  in  an  animal  from 


^  The  patient,  as  a  rule,  is  compelled  to  sit  up  in  bed,  if  he  is 
strong  enough ;  or  he  may  prefer  to  lie  on  the  sound  side.  Henoch 
gives  a  curious  case  of  a  man  with  pyo-pneumothorax,  who  when 
his  dyspnoea  became  extreme,  would  lie  on  his  back,  with  the 
upper  half  of  his  chest  below  the  level  of  the  lower  half,  and  in 
this  position  would  rid  himself  of  a  stream  of  pus  from  the 
mouth,  and  so  gain  relief  for  a  time.  Post  mortem,  there  was  found 
a  wide  communication  between  the  pleura  and  an  open  bronchus 
in  the  upper  part  of  the  compressed  lung. 

=  "History  of  the  War  of  the  Rebellion,"  Part  i. ;  Surgical 
Volume,  p.  623. 

3  "  On  the  advantages  of  pleural  adhesions  in  penetrating  wounds 
of  the  chest."     Melanges  de  Chirurgie.    Paris,  i8og. 


PNEUMOTHORAX.  73 

whom  a  great  part  of  the  wall  of  the  chest  has  been 

removed I  have  often,  on  dogs,  made  penetrating 

wounds  on  both  sides  of  the  chest,  larger  than  the  open- 
ing of  the  glottis,  and  I  know  that  an  animal  under 
these  conditions  lives  a  long  time,  and  dies  only  of  a  sort 
of  gradual  asphyxia.'  The  same  lesson  is  taught  both 
by  experiment  and  by  experience. 

1.  A  man,  aged  2>3i  stabbed  himself  m  the  fifth  left  inter- 
costal space,  inflicting  a  wound  three  inches  long.  At  the 
bottom  of  it  one  could  see  the  lung,  wounded  and  still  bleed 
ing,  but  with  no  sign  of  collapse.  The  wound  was  closed  ; 
no  pneumothorax  occurred,  only  slight  emphysema  :  and  he 
made  a  good  recovery. 

2.  A  woman,  run  over  by  a  waggon,  suffered  fracture  of 
several  ribs,  emphysema,  and  haemoptysis  ;  she  died  soon 
after  the  accident.  Post  mortem.,  there  was  found  severe 
laceration  of  the  lung  ;  '  but,  in  spite  of  this,  the  lung  was 
everywhere  in  apposition  with  the  chest-walls,  and  there  was 
a  complete  absence  of  pneuiuothorax.'  The  pleural  cavity 
was  free  from  adhesions. 

Now  it  is  not  a  question  of  difference  between  a  wound 
that  only  opens  the  pleura  without  injuring  the  lung,  and 
a  wound  that  penetrates  the  lung.  Doubtless  it  is  just 
possible  that  the  pleura  should  be  opened,  and  yet  the 
lung  should  escape.  But  when  we  consider  the  immediate 
apposition  of  the  lung  to  the  pleura,  and  remember  that 
it  is  the  smallest  wounds  of  the  lung  that  are  most  likely 
to  cause  pneumo-thorax,  it  is  plain  that  we  need  hardly 
think  of  those  most  rare  cases  where  the  injury  opens  the 
pleura,  but  stops  short  of  the  lung. 

Let  us  first  notice  some  arguments  that  help  to 
explain  the  matter. 

I.  We  do  not  yet,  in  spite  of  all  that  has  been  ob- 
served in  practice  or  proved  by  experiment,  fully  under- 
stand the  exact  causes  of  collapse  of  the  lung.  Experi- 
ments  are   still   being   made    to    settle    the    question, 


74  SURGERY    OF    THE    CHEST. 

but  at  present  we  must  admit  that  it  does  not  seem  to 
follow  the  invariable  laws  of  a  purely  physical  process. 

2.  'It  is  not  improbable  that  the  state  of  the 
patient's  strength  exerts  considerable  influence  upon  the 
production  of  collapse  of  the  lung,  the  accident  being 
more  likely  to  take  place  when  he  is  exhausted  by  shock 
and  loss  of  blood,  than  when  he  is  able  to  command  the 
free  use  of  his  respiratory  muscles.  In  the  latter  case, 
his  efforts,  which  are  often  very  violent,  enable  him 
effectually  to  resist  the  encroachment  of  the  air,  and 
even  to  force  the  lungs  somewhat  out  of  the  chest.'  ^ 

3.  In  the  case  of  gunshot  wounds,  the  substance  of 
the  lung  is  rather  bruised  than  clean  cut.  This  bruising 
would  tend  to  block  the  air-vesicles  and  smaller  bronchial 
tubes. 

4.  Adhesions  do  most  certainly  play  a  very  important 
part  in  preventing  pneumothorax  after  a  penetrating 
wound  of  any  kind.  We  know  how  common  these  are  in 
the  post  mortem  examination  of  cases  where  during  life 
there  was  no  reason  to  suspect  their  presence  ;  and  it  may 
be  noted  that  the  great  majority  of  knife  and  bullet  wounds 
in  Hospital  practice  are  inflicted  on  those  whom  poverty 
has  exposed  all  their  life  to  every  circumstance  most  likely 
to  favour  the  formation  of  adhesions.  In  the  army,  also, 
Billroth  has  especially  recorded  the  great  frequency  of 
adhesions  in  the  older  men  in  the  French  army.  There 
is  an  interesting  old  essay  on  this  subject  by  P.  J,  Roux, 
1809,  but  unfortunately  he  does  not  quote  any  cases. 
The  following  -  are  of  interest  here  : — 

I.     A  man,  aged  20,  was  stabbed  in  the  'back,  between  the 

'Gross,   "System  of  Surgery,"  ii.,  p.  368. 

=  Billroth,  "Clinical  Surgery"  (Syd.  Soc.  Transl.)  1881,  p.  190; 
Erichsen's  "Surgery,"  8th  ed.,  i.,  p.  832;  Nelaton's  "Lectures 
on  Surgery,"  edited  by  Atlee,  1855,  p.  55. 


PNEUMOTHORAX,  75 

left  scapula  and  the  spine.  There  was  a  moderate  amount  of 
haemorrhage  ;  no  dyspncea  ;  no  pneumothorax.  The 
wound  was  closed  with  strapping  ;  three  days  after  the 
injury,  the  wound  was  probed  ;  thereupon  severe  pleurisy 
occurred,  which  lasted  three  days.  '  From  the  symptoms  in 
this  case,  it  seems  possible  that  the  wound  had  perforated 
an  adhesion.' 

2.  '  I  had  once  under  my  care  a  woman  who  had  exten- 
sive emphysema  of  the  areolar  tissue  of  the  trunk  from 
fractured  ribs,  but  without  any  pneumothorax,  the  lung 
having  been  wounded  at  a  spot  where  it  was  attached  to  the 
walls  of  the  chest  by  old  adhesions,  and. the  air  having  passed 
through  them  into  the  areolar  tissue  of  the  body,  without 
first  entering  the  cavity  of  the  pleura.' 

3.  A  young  man  stabbed  himself  in  the  fourth  left  inter- 
'costal  space,  about  two  inches  from  the  sternum.  He 
fainted,  and  on  recovering  consciousness,  suffered  severe 
dyspncea.  Next  day,  there  was  emphysema  up  to  the 
clavicle  ;  great  oppression  ;  and  a  limited  pneumothorax  at 
the  wound  and  over  the  heart,  and  for  about  an  inch  below 
it.  '  How  was  it,  however,  that  respiration  could  be  heard 
all  over  the  chest  behind,  and  over  the  upper  half  of  it  in 
{"ront  ?  On  asking  the  patient,  it  was  found  that  he  had  been 
very  subject  to  pectoral  affections,  and  it  was  supposed  that 
in  consequence  the  lung  had  become  united  by  false  mem- 
branes to  the  walls  of  the  chest.' 

Still,  these  considerations  do  not  carry  us  far.  The 
real  reason  why  pneumothorax  is  so  rare  in  penetrating 
wounds  of  the  chest  is  given  in  Dr.  West's  most  valuable 
Bradshawe  Lecture.  Among  many  physical  experiments 
that  he  made,  the  following  must  be  noted  :  (i)  Two  discs 
of  wood,  perforated  in  the  centres,  were  covered  with 
pieces  of  stomach,  drawn  tight  over  them,  with  the  peri- 
toneal surface  outward.  When  pressed  together,  the 
discs  could  not  be  drawn  apart,  even  after  one  of  the 
membranes  had  been  incised,  by  the  exercise  of  a  force 
equal  to  the  normal  elastic  recoil  of  the  lung  :  (2)  Over 
the  mouth  of  a  bell-jar,  fitted  at  its  closed  end  with  an 
air-pump,  were  stretched  two  pieces  of  stomach,  with 
their  peritoneal  surfaces  in  apposition.      The  jar  was  ex- 


76     ■  SURGERY    OF    THE    CHEST. 

hausted  of  air  till  the  negative  pressure  within  it  became 
equal  to  the  force  exercised  by  the  normal  elasticity 
of  the  lung  :  then  a  slit  was  made  in  the  outer  of  the  two 
membranes.  They  still  remained  in  close  apposition. 
'  There  is  some  force,  other  than  atmospheric  pressure, 
by  which  these  two  smooth  surfaces  were  held  together ; 
and  without  using  the  term   in  too  technical  a  sense, 

I  may  speak  of  it  as  cohesion Pneumothorax, 

therefore,  is  a  condition  brought  about  by  the  forcible 
separation  of  the  pleural  surfaces,  and  in  this  respect  ex- 
actly analogous  to  the  distension  of  the  subcutaneous 
tissue  which  obtains  in  surgical  emphysema.  So  far  from 
being,  as  it  is  commonly  regarded,  a  passive  process,  and 
inspiratory  in  origin,  it  is  really  expiratory  in  its  origin, 
and  requires  an  active  force  to  produce  it.'^ 

We  have  now  gone  over  the  chief  causes  and  symptoms 
of  pneumothorax,  and  the  chief  points  of  treatment.  We 
must  further  remember  that  in  cases  of  injury  we  may 
have  blood,  as  well  as  air,  effused  into  the  pleura,  giving 
rise  to  a  different  set  of  physical  signs.  The  diagnosis  is 
in  most  cases  not  difficult ;  but  Frjintzel  records  that  he 
has  twice  mistaken  a  large  tubercular  cavity  for  pneumo- 
thorax. The  same  mistake  is  also  not  unlikely  to  be 
made  in  some  cases  of  subphrenic  abscess  containing  air. 
The  onset  of  pneumothorax  is  in  some  instances  so 
sudden  and  so  alarming,  and  the  questions  relating  to  it 
are  of  such  interest,  that  it  must  command  our  best  con- 
sideration ;  but  it  is  not  often  so  acute  or  so  serious  as  in 

^  It  is  probable  that  this  cohesion  is  not  equally  powerful 
over  the  whole  surface  of  the  lung  :  that  is  to  say,  the  more 
movable  part  of  the  lung,  near  its  edge,  would  slip  away  and 
allow  air  to  enter  the  pleura.  See  Mr.  A.  H.  Smith's  experi- 
ments, given  in  the  "History  of  the  American  War,"  Part  i., 
surgical  volume,  page  631 :  and,  above  all,  Mr.  Godlee's  paper 
in  the  "  Practitioner  "  a  few  years  ago. 


PNEUMOTHORAX.  77 

some  of  the  cases  here  quoted.  We  are  bound,  however, 
to  be  familiar  with  it,  and  to  be  ready  to  treat  it  without 
delay,  if  it  is  severe.  And  the  best  treatment,  if  the 
symptoms  do  not  abate  under  the  use  of  opium,  is 
probably  simple  puncture — not  aspiration,  lest  we  should 
re-open  the  small  perforation  in  the  lung.  In  certain 
cases  puncture  may  not  sufifice,  and  the  surgeon  may 
find  it  necessary  to  make  a  free  incision,  with  or  without 
resection  of  a  rib. 


78 


CHAPTER   VII. 

HERNIA     OF     THE     LUNG. 

The  signs  and  symptoms  of  hernia  of  the  lung  are  so 
remarkable,  and  its  course  and  treatment  afford  such 
pleasant  subjects  for  speculation,  that  we  are  in  danger 
of  forgetting  how  rare  it  is,  and  how  simple  its  treatment 
ought  to  be.  Out  of  more  than  twenty  thousand  wounds 
of  the  chest  in  the  American  war,  there  were  only  seven 
cases  of  hernia  of  the  lung.  In  the  Crimean  war,  not  a 
single  case  was  reported  in  our  army.  Samuel  Cooper 
saw  one  at  the  battle  of  Waterloo,  and  Guthrie  saw 
three  at  Brussels  after  the  battle.  Mr.  Erichsen  records 
one  only,  which  he  saw  in  Velpeau's  wards  in  1839.' 
For  the  study  of  the  whole  subject  we  have,  happily  for 
us,  Morel-Lavallee's  admirable  essay  and  collection  of 
32  cases,  and  from  him  and  other  writers  we  are  able  to 
understand  the  absorbing  interest  that  hernia  of  the  lung 
has  always  had  for  surgeons. 

We  are  not  now  concerned  with  those  cases  in  which  the 
lung  is  exposed  through  some  congenital  gap  in  the  ribs, 
or  with  those  one  or  two  recorded  cases  where  the 
apices  of  the  lungs  have  been  situated  so  high  as  to 
form  a  sort  of  hernia  above  the  clavicles  :  but  only  with 
cases  of  hernia  of  the  lung  due  to  injury.  Among  the 
possible  injuries  that  may   cause    it,    we   must   reckon 

'For  some  recent  cases,  see  Mr.  Pitts'  Lectures,  "Lancet," 
Oct.  14,  1893;  and  the  "Transactions  of  the  Ninth  Congress  of 
the  French  Surgical  Association,"  Paris,  1895.  -^  case  is  given 
in  Reclus'  paper  (see  Appendix),  and  Tuffier  has  operated  suc- 
cessfully for  the  "  radical  cure  "  of  chronic  hernia  of  the  lung. 


HERNIA    OF    THE    LUNG.  79 

coughing  or  straining.  Mr.  Erichsen  has  noted  a  case 
in  a  man  who  earned  his  Hving  by  playing  the  cornet:- 
Boerhave  saw  it  occur  after  child-birth  in  a  primipara. 
Chaussier  -  gives  a  case  of  hernia  of  each  lung,  with 
displacement  of  the  costal  cartilages.  Each  hernia  had 
occurred  after  a  severe  cough,  one  a  considerable  time 
before  the  other,  but  both  in  the  course  of  the  same  year. 
On  the  left  side,  between  the  eighth  and  ninth  ribs, 
there  was  a  large  hernia,  passing  through  a  ring  more 
than  two  inches  in  diameter.  The  cartilage  of  the  ninth 
rib  was  separated  from  the  bone ;  there  was  undue 
mobility,  and  slight  crepitation.  On  the  right  side  was  a 
smaller  hernia,  between  the  seventh  and  eighth  ribs. 
The  patient  had  no  trouble  from  them  ;  he  wore  an 
abdominal  belt,  and  held  his  hands  over  them  when  he 
coughed.  Probably  in  this  case  the  costal  cartilages 
had  been  broken  by  muscular  action  during  fits  of 
coughing,  thus  allowing  hernia  to  occur.  After  simple 
fracture,  it  may  not  begin  to  appear  for  many  weeks,  or 
even  a  much  longer  time,  after  the  accident. 

A  man,  aged  65,  fell  out  of  a  cart,  and  broke  the  sixth  and 
seventh  ribs  of  the  right  side,  about  the  junction  of  their  pos- 
terior and  middle  thirds.  Within  a  fortnight  of  the  accident 
he  removed  his  bandages,  at  the  bidding  of  a  quack  doctor  ; 
he  now  suffered  severe  pain,  and  soon  he  noticed  a  swelling, 
which  was  at  first  no  bigger  than  a  hazel-nut,  but  rapidly  grew 
larger.  At  first,  it  only  appeared  when  he  coughed  ;  then  it 
was  always  present.  Three  months  after  the  accident  it  was 
as  large  as  one's  fist,  and  had  not  gone  back  for  a  fortnight. 
It  was  soft,  even,  elastic,  passive,  easily  reducible  ;  the 
skin  over  it  was  natural  ;  it  moved  with  the  movements  of 
respiration,  swelling  in  inspiration,  falling  in  expiration,  be- 
coming distended  during  a  cough,  then  slowly  subsiding.     It 

'  Escape  of  air  into  the  cellular  tissue  of  the  body  has  also  been 
observed  under  these  conditions ;  see  chapter  on  Emphysema. 

^  "Bull,  de  la  Faculte  de  Med.,"  Paris,  1814,  iv.,  50;  quoted 
by  Gurlt. 


So    •  SURGERY    OF    THE    CHEST. 

was  not  painful,  but  gave  him  a  feeling  of  trouble,  oppression, 
dragging  inside  the  chest,  and  shortness  of  breath,  so  that 
he  would  pant  for  breath  after  a  cough.  He  wore  a  pad 
and  bandage  night  and  day  for  two  years,  then  only  by  day, 
and  thus  was  cured. 

Hernia  of  the  lung  from  direct  penetrating  wound  of 
the  chest  occurs  at  once,  or  at  the  latest  within  twenty- 
four  hours.  Still,  it  is  not  impossible  that  a  small  wound 
may  scar  over,  and  yet  hernia  may  afterward  occur 
beneath  the  scar. 

A  man,  aged  29,  in  a  duel,  was  wounded  with  a  rapier  just 
below  and  to  the  inner  side  of  the  left  nipple.  '  How  deep 
was  the  wound  ?  One  could  hardly  tell  ;  but  he  had  no  severe 
pain,  no  palpitation  of  the  heart,  no  severe  shock  ;  there  was 
no  haemoptysis,  no  great  dyspnoea,  nothing  to  indicate 
haemorrhage  into  the  pleural  cavity  ;  very  little  bleeding' 
from  the  wound.'  By  the  fourth  day  all  bleeding  had 
ceased,  but  he  complained  of  sharp  pain  referred  to  the  left 
shoulder,  and  had  a  short  hacking  cough.  A  week  after  the 
injury  the  wound  was  healed,  but  he  still  had  a  cough, 
and  was  short  of  breath.  Six  weeks  after  the  injury,  he  first 
noted  a  swelling  under  the  scar,  and  was  found  to  have 
hernia  of  the  lung. 

Setting  aside  these  very  rare  cases  of  secondary  hernia, 

we  come  to  the  common  form  of  hernia,  where  the  lung 

protrudes,  at  once  or  in  a  few  hours,  through  a  wound  of 

the  chest  wall. 

1.  A  child,  aged  13,  fell  from  a  height,  coming  down  on  a 
sharp  piece  of  wood,  and  suffered  extensive  laceration  of  the 
fifth  right  intercostal  space  near  the  sternum.  The  surgeon, 
called  at  once,  found  free  bleeding  from  the  interior  of  the 
chest,  and  a  large  hernia  of  the  lower  lobe  of  the  lung.  The 
condition  of  the  patient  appeared  hopeless  ;  intense  oppres- 
sion and  distress,  frightful  pallor,  a  feeble  pulse,  cold  hands 
and  feet.  There  was  no  haemoptysis.  The  protruding 
portion  of  lung  was  with  some  difficulty  reduced,  and  the 
wound  was  closed.  The  child  remained  in  a  state  of  shock 
for  three  days  ;  then  came  excessive  reaction,  which  was 
treated  by  venesections.    Complete  recovery.  (Angelo,  1844.) 

2.  A  man,  while  drunk,  received  a  penetrating  wound 
below  the  left  nipple,  but  was  too  drunk  to  heed  it,  or  to  call 


HERNIA    OF    THE    LUNG.  8i 

for  help.  The  next  day  he  found  a  protruding  portion  of 
the  king,  of  three  fingers'  breadth.  He  now  took  a  two  days' 
journey  to  Amsterdam,  with  the  lung  still  hangings  out, 
unheeded  and  undressed.'  Tulpius  ligatured  it,  and  cut  it 
off  with  scissors:  it  weighed  three  ounces — "poids  enorme 
pour  un  viscere  si  rare  et  si  leger."  The  patient  healed 
quickly,  and  had  no  further  trouble,  save  a  cough  at  times. 
(Tulpius,  1674.) 

3.  A  young  soldier  in  the  American  war  was  shot  in  the 
left  side  of  the  chest,  a  little  below  the  nipple.  '  Our  atten- 
tion was  called  to  him  the  night  after  the  battle.  He  was 
lying  upon  the  ground  in  a  condition  of  considerable  prostra- 
tion. The  hernia  was  about  one  inch  in  diameter,  having 
escaped  from  an  aperture  which  was  very  much  smaller.  It 
was  completely  strangulated,  being  quite  black,  and  insensible 
to  the  touch.  We  applied  to  the  neck  of  the  hernia  a  strong 
silk  ligature.  .  .  .  We  saw  him  the  next  morning  lying 
in  the  same  place  ;  he  had  lain  without  shelter  two  nights, 
each  night  in  a  drenching  rain  ;  in  this  respect  he  suffered, 
however,  only  in  common  with  at  least  two  thousand  other 
wounded  and  dying  men.'  The  boy  was  moved  into  Hospital. 
The  issue  of  the  case  is  not  known. 

From  these  cases,  which  are  none  the  worse  for  being 
old,  we  may  draw  a  good  clinical  picture  of  hernia  of  the 
lung  after  injury.  It  will  be  observed  that  the  wound 
is,  as  a  rule,  of  some  considerable  size.  Poland,  in 
saying  that  it  is  usually  a  small  wound,  is  opposed  to  the 
general  opinion  on  this  point.  The  symptoms  that  we 
should  expect  to  attend  the  sudden  displacement  of  the 
lung  are  not  very  definite,  and  are  mostly  lost  in  those 
of  the  original  injury.  The  front  and  sides  of  the 
chest,  especially  the  lower  intercostal  spaces,  are  the 
most  common  sites  of  hernia ;  and  it  is  usually  the 
thin  mobile  edge  of  the  lung  that  is  concerned  in  it. 
There  is  evidence,  both  experimental  and  clinical,  to 
show  that  even  though  the  lung  itself  be  wounded,  the 

'"Die  Lungen  ein  ungemein  tolerantes  Organ  sind."  Ried- 
inger.  "  Le  poumon  est  pour  le  traumatisme  chirurgical  ou 
operatoire  un  organe  extremement  tolerant."     Michaux. 

6 


82  SURGERY    OF    THE    CHEST. 

wounded  part  may  yet  be  protruded.  Extensive  pneumo- 
thorax, or  old  adhesions  at  the  seat  of  injury,  would 
of  course  render  hernia  impossible. 

How  is  it  affected  by  inspiration  and  expiration  ?  It  is 
certain  that  more  than  one  case  has  been  reported  where 
the  surgeon  had  no  doubt  that  the  hernia  increased  on 
inspiration,  and  sank  on  expiration.  Against  these  re- 
reports.  Morel- Lavallee,  and  Otis,  in  the  History  of  the 
American  War,  declare  most  emphatically  that  those  who 
published  them  must  simply  have  been  mistaken.  '  We 
must  believe  that  these  statements  of  the  augmentation  of 
the  tumour  being  synchronous  with  inspiration,  were  all 
founded  on  faults  of  memory  or  errors  of  observation.' 
And  certainly  it  is  hard  to  see  how  any  act  of  inspiration 
could  overcome  the  pressure  of  the  atmosphere.  But  I 
suppose  it  is  possible  that,  in  a  secondary  hernia,  the  con- 
dition of  the  herniated  portion,  and  its  relations  to  the 
adherent  tissues  round  it  may  be  so  altered  that  this 
portion  may  not  behave  like  the  rest  of  the  lung. 

Slow  natural  expiration,  so  far  as  we  know,  would  not 
cause  increase  of  the  hernial  swelling.  But  sudden,  violent 
expiration,  and  especially  coughing  or  straining,  are  what 
cause  and  aggravate  it.  Like  emphysema  and  pneumo- 
thorax, it  is  an  expiratory  process.  Though  in  ordinary 
expiration  the  lung  retreats  or  is,  as  it  were,  pushed  back 
as  the  chest  contracts,  we  have  in  violent  and  sudden  ex- 
piration a  very  different  state  of  things.  The  glottis  is 
closed  or  nearly  closed  ;  the  air  in  the  lungs  is  suddenly 
put  under  increased  pressure.  A  sudden  knife  or  gunshot 
wound  of  the  chest  is  followed  by  an  immediate  forced 
expiration  with  closed  or  half-closed  glottis,  raising  the  pres- 
sure in  both  lungs,  or  causing  overflow  of  air  from  the  sound 
into  the  injured  lung,  and  thus  the  hernia  is  brought  about. 
Without  cough  or  violent  expiration,  it  could  not  occur. 


HERNIA    OF    THE    LUNG.  83 

A  hernia  that  has  come  gradually,  not  at  once,  may 
possess  a  true  sac,  lined  with  pleura.  It  may  be  wholly 
free  from  adhesions,  and  reducible ;  but  the  lung  does 
not  fly  back,  or  empty  itself  on  pressure,  like  a  hernia 
of  the  bowels. 

Cases  are  recorded  where  hernia  of  omentum  has 
been  mistaken  for  hernia  of  the  lung,  and  vice  versa. 
Chronic  abscess  of  the  chest  wall  has  also  been  mistaken 
for  it.  And  the  difficulties  of  diagnosis  will  be  great 
indeed  if  the  diaphragm  has  been  torn,  so  that  the 
bowels,  ascending  into  the  thorax,  simulate  a  hernia  of 
the  lung,  or  are  added  to  it,  as  in  the  followmg  cases  : — 

1.  A  man,  aged  ^I'ii  was  crushed  under  a  gun-carriage. 
His  condition  at  first  seemed  hopeless.  Blood  poured  from 
his  mouth  and  nose  ;  he  was  collapsed,  and  had  frequent 
attacks  of  syncope  ;  but  he  survived,  and  partly  recovered, 
and  for  the  next  seven  years  just  dragged  about  from  one  Hos- 
pital to  another.  In  the  eighth  left  intercostal  space,  at  the 
junction  of  ribs  and  cartilages,  was  a  small  tense  tender  irre- 
ducible swelling,  about  an  inch  across.  'On  any  exertion 
it  increases  in  size  ;  at  times  it  becomes  as  large  as  a  hen's 
^gg.,  and  is  then  very  hard,  and  exquisitely  tender,  and 
moreover  causes  all  the  symptoms  of  a  strangulated  hernia — 
hiccough,  nausea,  vomiting,  abdominal  pains,  retraction  of 
the  abdominal  wall — and  he  lies  on  the  affected  side, 
pressing  his  hands  to  his  abdomen.'  He  was  unable  to  bear 
the  pressure  of  a  bandage,  and  left  the  Hospital.  (Cloquet, 
1819.) 

2.  A  soldier  received  a  gunshot  wound  in  the  eighth  left 
intercostal  space,  fracturing  the  ninth  rib  ;  there  was  no  sign 
that  the  lung  was  wounded  ;  he  walked  a  mile  and  a  half  to  the 
rear,  and  entered  a  field  Hospital.  There  was  a  protrusion  of 
the  lung  of  the  size  of  a  small  orange  ;  it  could  not  be  reduced, 
even  after  enlarging  the  wound.  Next  day,  after  further  vain 
attempts  at  reduction,  it  was  ligatured,  and  sloughed,  leaving 
healthy  granulations.  It  slowly  healed,  but  there  remained 
a  troublesome  hernia  under  the  scar,  preventing  him  from 
further  active  service.  Three  and  a  half  years  after  the  injury 
the  swelling  became  suddenly  enlarged,  as  he  was  straining 
to  lift  a  heavy  weight.  A  note  of  the  case  two  months  later 
says,  '  It  now  measures  five  inches  by  four  and  a  half.    There 


84     '  SURGERY    OF    THE    CHEST. 

IS  often  nausea  after  eating,  and  great  pain.  Pressure  over 
the  swelling  causes  a  gurgling  sound  in  it,  and  sounds  of 
movement  of  the  bowels.  Traction  on  it  causes  nausea.  A 
portion  of  the  stomach  has  undoubtedly  escaped  through  the 
diaphragm,  and  through  the  opening  in  the  thoracic  walls.' 
Five  years  later  he  was  in  better  health,  and  the  swelling  was 
rather  smaller,  and  less  troublesome.     (Amer.  War,  1863.) 

But  as  a  rule,  the  nature  of  the  protrusion  is  evident ;  its 
history,  its  movements  in  respiration,  the  feel  of  it,  the 
fine  vesicular  murmur  or  crackling  sounds  on  auscultation, 
the  resonance  on  percussion — all  guide  us  to  a  right 
diagnosis. 

As  regards  prognosis,  it  is  to  be  noted  that  after 
the  first  occurrence  of  the  hernia  there  is  no  fear  that 
it  will  at  any  later  period  become  strangulated.  Even 
in  traumatic  hernia  the  prognosis  is  fairly  good.  '  In 
eight  cases  of  this  kind — though  in  every  one  of  them, 
according  to  the  surgeon  who  observed  it,  the  lung  was 
lacerated,  bloodless,  or  gangrenous — and,  let  me  add, 
though  the  treatment  was  irrational,  only  one  patient  died, 
and  the  rest  did  not  show  a  single  sign  of  serious  trouble. '^ 

It  is  necessary  to  remember  that  a  piece  of  lung  thus 
exposed  and  constricted  very  quickly  becomes  hard,  dry, 
and  dark,  and  yet  may  not  be  strangulated  past  recovery. 
'  They  have  made  this  mistake,  almost  all  of  them,' 
says  Morel-Lavallee,  '  and  that  is  why,  in  almost  every 
case,  they  have  cut  away  the  lung,  instead  of  reducing  it.' 
lioyer  ~  says  the  same.  '  One  might  easily  mistake  the 
dry  dusky  look  of  the  exposed  lung  for  strangulation,  and 
therefore  cut  off  a  portion  which  one  ought  to  save, 
Loyseau  had  a  case  where  a  man  received  an  extensive 
sword-wound  in  the  third  right  intercostal  space.  A 
portion  of  lung  escaped,  became  swollen,  and  remained 

'  Morel-Lavallee. 
=  "Traite  des  Maladies  Chirurgicales,"  1824,  vii.,  p.  266. 


HERNIA    OF    THE    LUNG.  85 

for  three  or  four  days  unreduced.  It  became  shrunken 
and  dry,  was  considered  gangrenous,  and  was  cut  off 
level  with  the  skin.  But  when  one  put  the  piece  re- 
moved into  water,  it  regained  its  natural  colour,  as  doubt- 
less it  would  have  done  if  one  had  reduced  it.' 

Perhaps  we  cannot  trust  this  last  sentence ;  but  it  is 
certain  that  a  hernia  may  appear  badly  strangulated,  when 
it  will  yet  recover  if  put  back  inside  the  chest.  But  is 
reduction  so  easy  ?  There  are,  at  most,  only  a  few 
recorded  cases  where  it  was  found  possible.  Steady 
pressure,  while  an  assistant  with  blunt  hooks  retracts  the 
ribs,  and  the  patient  slowly  draws  a  deep  breath,  may  be 
successful ;  or  it  may  be  necessary  slightly  to  enlarge  the 
wound.  Should  these  measures  fail,  it  is  hard  to  see 
what  is  gained  by  the  ligature.  Poland  mentions  two 
cases,  where  the  exposed  lung,  left  to  itself,  gradually  re- 
ceded till  it  became  level  with  the  skin,  and  so  healed. 
Guthrie  says  of  the  three  cases  that  he  saw  at  Brussels, 
after  Waterloo,  '  They  were  not  interfered  with,  greatly  to 
the  advantage  of  the  patients.'  The  surgeon  therefore  had 
best  be  content  with  keeping  the  exposed  lung  in  such 
dressings  as  may  ensure  its  vitality  and  safety  from 
infection. ' 

That  one  page  at  least  of  this  book  may  be  beyond 
the  blame  of  being  dull,  I  transcribe  a  case  four  hundred 
years  old.  '  Called  to  a  citizen  of  Bologna  on  the  sixth 
day  after  his  wound,  I  found  a  portion  of  the  lung  issued 
between  two  ribs  ;  the  afflux  of  the  spirits  and  humours 
had  determined  such  a  swelling  of  the  part,'  that  it 
was  not  possible  to  reduce  it.  The  compression  exercised 
by  the  ribs  retained  its. nutriment  from  it,  and  it  was  so 

'  Couvy  collected  14  capes  treated  by  removal  of  the  protrusion, 
with  12  recoveries.  Heydweiller  advises  removal,  as  more 
reasonable  and  more  sure  of  success  than  non-interference. 


86  SURGERY    OF    THE    CHEST. 

mortified  that  worms  had  been  developed  in  it.  They  had 
brought  together  the  most  skilful  chirurgeons  of  Bologna, 
who,  judging  the  death  of  the  patient  to  be  inevitable, 
had  abandoned  him.  But  I,  yielding  to  his  prayers,  and 
to  those  of  his  parents  and  his  friends,  and  having 
obtained  the  leave  of  the  Bishop,  the  master,  and  the 
man  himself,  I  yielded  to  the  solicitations  of  about 
thirty  of  my  pupils,  and  made  an  incision  through  the 
skin,  the  breadth  of  my  little  finger-nail  away  from  the 
wound,  all  round  it.  Then,  with  a  cutting  instrument, 
I  removed  all  the  portion  of  the  lung  level  with  my 
incision.  The  wound  resulting  from  this  resection  was 
closed  by  the  blood  issuing  from  my  incision,  and  was 
dressed  frequently  with  the  red  powder  and  other  ad- 
juvants. By  the  grace  of  God  it  cicatrised,  and  recovery 
took  place.  It  is  true  that  one  had  to  wait  long  for  it. 
The  patient,  with  his  master  Rolandini,  has  since  then 
made  the  voyage  to  Jerusalem,  and  has  returned  in  good 
health. 

'  If  you  ask  me  what  I  should  have  done  in  this  case,  if 
I  had  been  called  to  it  at  once,  I  answer  that  I  should  have 
dilated  the  wound  with  a  small  piece  of  wood,  keeping 
the  lung  warm  with  a  cock  or  a  fowl  split  down  the  back, 
and  should  then  have  reduced  it,  and  kept  the  wound 
open  till  the  portion  of  lung  was  wholly  mortified.  If 
you  still  question  me,  to  know  how  this  man  can  live 
without  his  lung,  I  answer  that  the  part  remaining  within 
the  chest  profits  by  the  nutriment  destined  for  the  whole 
of  the  lung,  and  so  is  developed,  and  that  nature  has 
been  able  to  create  supplementary  parts  in  it,  which  is  an 
easy  thing  in  an  organ  that  is  soft  and  near  the  warmth  of 
the  heart.' 

Rolandus  published  this  case  in  1499. 


87 


CHAPTER   VIII. 

WOUNDS    OF    THE    INTERCOSTAL    AND    INTERNAL 
MAMMARY  ARTERIES.     HEMOTHORAX. 

We  now  approach  one  of  the  greatest  and  most  vital 
subjects  in  surgery — the  course  and  treatment  of  pene- 
trating wounds  of  the  chest.  We  must  not  in  any  way 
neglect  the  usual  division  into  penetrating  and  non- 
penetrating wounds  ;  but  on  the  other  hand  we  must  not 
make  too  much  of  it.  We  may  be  quite  unable  to  say 
whether  a  wound  has  or  has  not  penetrated  the  chest ; 
and  we  may  make  a  mistake  in  such  a  case  if  we  do 
too  much  to  satisfy  ourselves  on  this  point.  And  this 
division,  again,  by  no  means  indicates  the  extent  or 
gravity  of  the  injury.  'An  innocuous  puncture  with  a 
capillary  trochar  is  a  penetrating  wound,  and  rupture  of 
the  heart  or  laceration  of  the  lungs  without  external 
wound  is  a  non-penetrating  wound.'  As  in  wounds  of 
the  head  or  abdomen,  so  here,  our  chief  thought  is  for  the 
contents  of  the  cavity,  not  for  the  cavity  itself. 

We  have  already  given  attention  to  emphysema  and 
pneumothorax.  The  third,  most  common,  and  most 
dangerous  result  of  wounds  of  the  chest  remains  for  our 
consideration — haemorrhage,  either  through  the  wound, 
or  running  unseen  into  the  pleural  cavity,  or  coughed 
up  through  the  mouth,  or  all  three  altogether. 

But,  before  we  come  to  wounds  of  the  lung,  there  is  a 
set  of  cases  standing  on  the  border  line  of  the  old  division 
between  penetrating  and  non-penetrating  wounds — cases 
of  wound  of  the  intercostal  or  internal  mammary  vessels. 


88  SURGERY    OF    THE    CHEST. 

Happily,  they  are  seldom  wounded.  When  they  are,  the 
injury  is  often  fatal,  and  often  not  recognized  by  the 
surgeon.  With  the  wounds  of  these  vessels  we  may  also 
consider  in  this  chapter  the  course  and  treatment  of 
haemothorax :  thus  clearing  the  way  for  a  general  con- 
sideration of  wounds  of  the  lung.  , ,      . 

Wounds  of  the  Intercostal  Arteries. 

In  the  study  of  the  surgery  of  this  or  that  region  or 
organ  of  the  body,  one  naturally  is  most  interested  in  the 
record  of  any  case  where  the  surgeon  himself  has  in- 
flicted the  injury.  I  put  first,  therefore,  two  instances  ^ 
where  an  intercostal  artery  was  wounded  in  the  operation 
for  empyema. 

1.  A  young  man  was  admitted  to  Hospital  with  empyema 
of  the  left  side,  consequent  on  a  penetrating  gunshot  wound 
of  the  chest.  The  empyema  communicated  with  an  abscess 
of  the  chest-wall  which  had  aheady  been  incised.  The 
surgeon,  to  enlarge  the  opening  into  the  chest  so  that  he 
might  wash  out  the  empyema,  made  an  incision  into  one  of 
the  intercostal  spaces.  This  was  followed  by  haemorrhage  ; 
the  patient  became  collapsed  and  unconscious,  and  died. 
Fosi  mortem^  a  small  incision,  f  inch  long,  was  found  in  the 
intercostal  artery. 

2.  A  man,  aged  45,  was  admitted  to  Hospital  suffering 
with  empyema  of  the  left  side,  gangrene  of  the  lung,  and 
pneumothorax.  Aspiration  had  given  very  transient  relief, 
and  his  condition  was  almost  hopeless.  A  free  incision  was 
made  in  the  seventh  intercostal  space,  and  more  than  a 
quart  of  foetid  blood-stained  pus  escaped  under  great 
pressure.  Four  or  five  minutes  later  he  beca'me  very  pale, 
was  bathed  in  sweat,  and  the  dressings  were  soaked  with 
blood.  They  were  removed,  and  blood  was  found  bubbling 
over  the  lower  edge  of  the  wound,  but  in  no  great  quantity. 
The  finger,  passed  into  the  wound,  felt  a  hot  jet  of  blood 
directed  against  it.     The  hosmorrhage  was  stayed  with  a  plug 

"  Dulac  :  "  De  la  Blessure  des  Ar teres  Intercostal es  dans  les 
Plaies  de  Poitrine,  et  particulierement  dans  la  Paracentese," 
These  de  Paris,  1874. 


WOUNDS    OF    THE   MAMMARY   ARTERIES.         89 

pressed  up  into  the  groove  for  the  intercostal  vessels  and 
nerve  ;  but  the  patient  died  almost  at  once.  Posi  viorteni., 
a  wound  |  inch  in  length  was  found  in  the  intercostal  artery. 
The  specimen  from  this  case  is  shown  in  Plate  II. 

Happily,  this  'calamity  of  surgery'  must  be  very 
rare.  I  can  find  no  further  record  of  it.  Frantzel'  says  : 
'  I  have  never  seen  the  main  trunk  of  an  intercostal 
artery  wounded  in  incision  of  the  chest ;  one  can  always 
avoid  it.  But  I  have  twice  wounded  a  branch  of  it ;  and 
in  one  case,  where  the  artery  lay  deep  beneath  a  thick 
covering  of  muscles,  I  had  considerable  haemorrhage, 
which  it  was  difficult  to  stop.  It  is  hardly  possible  to  tie 
the  bleeding  point;  one  must  therefore  have  resort  to 
compression,  taking  care  that  blood  does  not  still  pass, 
unnoted,  behind  the  plug  into  the  pleural  cavity.' 

By  numerous  experiments  on  the  dead  body,  Dulac 
found  that  an  intercostal  artery  can  be  easily  wounded  by 
an  incision  close  to  the  lower  border  of  the  upper  rib, 
either  in  the  sixth,  seventh,  or  eighth  space,  alike  in  the 
anterior,  lateral,  or  posterior  part  of  the  chest. 

The  following  cases  "  clearly  illustrate  the  usual  cause 
and  course  of  wounds  of  the  intercostal  arteries. 

I.  A  wood-cutter  wounded  himself  in  the  left  side  of  the 
chest  with  a  bill-hook.  '  Called  to  him  a  few  minutes  after 
the  accident,  I  found  him  lying  on  his  back,  with  an  irregular 
transverse  wound  below  the  left  nipple  ;  a  little  blood  flowed 
from  it.  From  the  direction  and  size  of  the  wound,  and  the 
shape  and  length  of  the  bill-hook,  I  was  of  opinion  that  the 
wound  had  penetrated  the  chest.  His  breathing  was  easy  ; 
neither  the  colour  of  the  blood,  nor  any  issue  of  air  from  the 
wound,  pointed  to  injury  of  the  lung.  I  bled  him  freely 
at  once,  and  applied  a  compress  and  a  bandage.  Two  hours 
later  I  saw  him  again  ;    he  was  lying  on  the  wounded  side, 

'  Ziemssen's  Handbuch,  loc.  cit.,  1875. 

^  For  references,  see  Dulac,  loc.  cit. :  History  of  the  War  of  the 
Rebellion.  The  first  two  cases  are  many  years  old,  but  they  are 
none  the  less  worthy  of  consideration. 


go  SURGERY    OF    THE    CHEST 

his  face  blanched,  his  pulse  small  and  rapid,  his  breathing 
difficult  and  oppressed  :  and  there  was  dulness  over  the 
wounded  side  of  the  chest.  There  was  thus  no  doubt  that  he 
had  blood  in  the  left  pleura.  But  what  was  the  source  of 
the  hcemorrhage?  There  was  no  sign  of  any  wound  of  the 
lung.  The  sharp  concave  edge  of  the  bill-hook  had  been 
turned  outward  ;  the  blunt  edge  had  been  toward  the  lung. 
It  therefore  seemed  probable  that  an  intercostal  artery  had 
been  wounded,  and  I  advised  that  the  wound  should  be 
re-opened,  and  the  artery  compressed.  This  advice  was 
opposed,  and  he  was  again  bled  trom  the  arm  ;  his  breathing 
became  worse,  violent  convulsions  set  in,  and  he  died  in 
half-an-hour.  Pos^  jnor/etn,  the  left  pleura  was  full  of  blood  ; 
the  diaphragm  was  pushed  downward  ;  the  lung  was  pushed 
backward  and  upward,  slightly  bruised  at  one  point,  but  not 
wounded.  The  wound  had  laid  open  the  sixth  intercostal 
space,  and  had  cut  the  lower  edge  of  the  fifth  rib,  the  nerve, 
and  the  artery.' 

2.  A  man,  aged  34,  bent  on  suicide,  stabbed  himself  in 
the  third  left  intercostal  space,  '  about  an  inch  deep.'  He 
withdrew  the  knife,  and  fell.  '  There  was  at  once  a  severe 
haemorrhage,  with  all  the  signs  of  a  penetrating  wound  with 
injury  of  the  lung.'  (It  is  not  said  that  there  was  any  haemo- 
ptysis). He  was  admitted  to  Hospital,  the  wound  was 
dressed  and  bandaged  ;  throughout  the  night  he  suffered 
severe  oppression,  and  frequently  fainted.  '  Next  morning, 
we  found  the  dressings  and  the  bed  soaked  with  blood  ; 
his  face  was  pale,  his  lips  colourless,  his  eyes  dull  and 
glazed  ;  bright  blood  trickled  from  the  wound  ;  its  edges 
were  swollen,  crepitant,  and  here  and  there  fluctuant ;  his 
extremities  were  cold,  pulse  small,  breathing  difficult  and 
laboured.  Plainly  he  was  bleeding  either  from  the  lung,  or 
from  an  intercostal  artery  ;  and  I  suspected  the  latter.  I  en- 
larged the  wound,  turned  out  a  quantity  of  clots,  and 
examined  it  with  my  finger  ;  cleaned  it  well,  and  found 
bright  blood  issuing  from  between  the  intercostal  muscles 
where  his  knife  had  cut  them.  I  divided  some  of  the 
muscular  fibres,  and  with  a  fine  curved  needle  succeeded  in 
tying  the  artery  at  once.'  The  efi'usion  of  blood  into  the  pleura 
was  followed  by  empyema.     The  patient  finally  recovered. 

3.  A  young  soldier,  aged  17,  received  a  penetrating  gun- 
shot wound  of  the  chest,  fracturing  the  ninth  left  rib,  three 
inches  from  the  spine,  and  wounding  the  lung.  For  three 
weeks  he  did  well  :  the  lung  seemed  healed,  and  the  wound 
was  healing.       On  the  twenty-third  day  severe  secondary 


WOUNDS    OF   THE   MAMMARY   ARTERIES.        91 

haemorrhage  came  from  the  wound  ;  the  bed  was  soaked 
with  blood,  and  the  patient  was  almost  unconscious.  '  I 
slightly  enlarged  the  wound  and  removed  some  fragments  of 
bone.  Meanwhile  the  arterial  jet  was  becoming  stronger, 
and  the  patient  momentarily  weaker  ;  there  was  evidently  no 
time  to  be  lost.'  Digital  pressure  was  kept  up  ;  chloroform 
was  given,  and  with  a  blunt  curved  needle  on  a  handle  the 
whole  rib  was  ligatured  on  either  side  of  the  fracture.  The 
bleeding  stopped  at  once,  but  the  patient  sank  and  died  two 
hours  later.  Fos^  mor/em,  it  was  found  that  the  ligatures 
had  been  passed  round  the  rib  successfully  without  lacer- 
ating the  pleura. 

4.  A  soldier,  aged  26,  received  a  gunshot  wound  of  the 
chest,  fracturing  the  eighth  and  ninth  ribs,  but  not  wounding 
the  lung.  He  suffered  Irom  rigors,  with  profuse  sweating  ; 
and  on  the  ninth  day,  considerable  secondary  haemorrhage 
came  from  the  wound.  The  wounds  of  entrance  and  of  exit 
were  laid  open  into  one  incision,  the  fractured  ends  of  the 
ribs  were  cut  off  with  the  bone-forceps,  and  the  intercostal 
artery  was  picked  up  and  ligatured.  '  The  pleural  cavity 
did  not  seem  to  have  been  opened  by  the  ball.  But  the 
motion  of  the  cut  end  of  the  rib  wore  an  opening,  and  also 
divided  the  artery,  and  hemorrhage  again  occurred  ;  two 
days  after  the  operation  the  vessel  was  again  tied,  and  the 
rib  cut  off  still  lurther.'  The  patient  died  of  exhaustion 
about  a  month  after  the  injury. 

5.  A  soldier  received  a  penetrating  gunshot  wound  of  the 
chest  ;  the  ball,  passing  out,  fractured  the  tenth  right  rib  and 
the  lower  angle  of  the  scapula.  A  fortnight  later,  secondary 
haemorrhage  occurred  several  times  during  the  night,  and  in 
the  morning  the  skin  was  found  swollen  with  blood,  and  the 
patient  was  blanched  and  very  feeble.  Under  an  anaesthetic 
the  wound  was  enlarged,  spicules  of  bone  were  removed,  a 
quantity  of  clot  was  turned  out,  and  the  artery  was  ligatured. 
No  further  bleeding  occurred,  and  for  a  time  he  did  well  ; 
but  he  died  of  empyema  about  a  month  later.  Fos/  7nortem, 
the  lung  had  been  wounded,  and  was  adherent  ;  there  was 
dark  unhealthy  pus  in  the  pleura  ;  the  fractured  ends  of  the 
rib  were  necrosed. 

6.  A  young  soldier,  aged  18,  received  a  gunshot  wound 
of  the  chest,  the  ball  entering  the  fifth  left  intercostal  space, 
and  lodging  in  the  lung.  On  the  eighth  and  again  on  the 
ninth  day,  secondary  haemorrhage  occurred  from  the  inter- 
costal artery.  An  attempt  was  made  to  ligature  the  vessel, 
but  from  the  narrowness  of  the  intercostal  space,  and  the 


92  SURGERY    OF    THE    CHEST. 

depth  of  the  wound,  it  was  found  impracticable.  He  died 
the  same  day.  Fosi  mortem^  2l  quantity  of  blood  was  found 
in  the  pleura.  He  had  lost  nearly  a  pint  of  blood  on  the 
occasion  of  the  last  secondary  haemorrhage. 

But  these  cases  give  a  one-sided  view  of  the 
treatment  of  a  wounded  intercostal  artery.  In  the 
American  war,  out  of  a  total  of  15  cases,  variously 
treated,  11  ended  in  death.  In  8,  an  operation  was 
performed ;  of  these,  6  died  :  one  from  pyaemia,  one  from 
empyema,  one  from  exhaustion,  and  three  from 
secondary  haemorrhage.  '  The  operations  had  scarcely 
more  successful  results  than  the  cases  treated  by  com- 
pression.' Are  we  then  justified  in  believing  that  it  is 
not  necessary  to  operate  in  these  cases,  or  to  do  more 
than  plug  the  wound  ?  ^ 

In  any  case  of  secondary  haemorrhage  from  an  intercos- 
tal artery,  the  surgeon  ought  to  operate  at  once,  and  will 
probably  have  to  resect  a  piece  of  rib."  He  must  remember 
that  the  bleeding  is  most  serious,  and  the  artery  most 
difficult  of  access,  in  the  posterior  part  of  the  chest.  In 
any  case  of  primary  haemorrhage,  he  will  probably  have 
immediate  recourse  to  digital  compression  of  the  wound, 
followed  by  plugging  with  a  well-fitted  compress  :  not  be- 
cause he  thinks  compression  is  in  itself  better  than 
ligature,  or  so  good,  but  because  of  the  enfeebled  state  of 
the  patient,  or  because  there  is  reason  to  think  that  the 
bleeding  is  from   the  lung.     But  such  a  case  must  be 

'  The  best  method  of  compression  is  that  given  by  Desault.  A 
square  piece  of  lint  is  pressed  into  the  wound,  then  its  four 
corners  are  brought  together  so  that  it  forms  a  pocket,  and  this 
is  tightly  packed  with  lint  so  that  the  whole  wound  is  well  com- 
pressed. 

=  Innumerable  methods  were  devised  by  the  older  surgeons — 
trephining  the  rib  ;  drilling  it ;  introducing  discs  of  metal ;  using 
various  ways  of  passing  a  ligature — "some  dangerous,  others' 
trivial,  and  others  more  ingenious  than  useful." 


WOUNDS    OF   THE    MAMMARY   ARTERIES.        93 

watched  from  hour  to  hour,  and  he  must  be  prepared  to 
interfere  at  any  moment,  to  open  the  wound  freely,  and 
to  expose  the  artery,  or  even  the  lung  itself. 

An  isolated  wound  of  the  artery,  without  wound  of  the 
lung,  is,  of  course,  very  rare.  One  may  suspect  it  if  the 
wound  be  of  such  a  depth  and  direction  as  to  cause  it ;  if 
there  be  external  haemorrhage,  or  hasmothorax,  or  both, 
without  haemoptysis  or  pneumothorax ;  if  the  exter- 
nal haemorrhage  be  arterial  in  colour,  but  unmixed 
with  air;  and  if  the  finger,  introduced  into  the 
wound,  feel  a  jet  of  blood  spurting  on  it.  It  is  useless  to 
try  the  old  method  of  laying  a  thin  edge  of  something, 
such  as  a  card,  in  the  wound,  to  see  if  the  blood  flows 
from  above  it  or  from  beneath  it;  one's  finger  is  alone  likely 
to  be  useful.  Riedingeri  puts  the  subject  very  clearly. 
Having  enumerated  all  the  complicated  devices  of  the 
older  surgeons,  he  says,  '  It  is  really  wonderful,  at  the 
present  time,  how  so  many  great  surgeons  were  possessed 
with  the  idea  that  an  intercostal  artery  could  not  be 
secured  without  all  these  contrivances.  If  you  can't  stop 
the  bleeding  by  plugging  the  wound,  you  must  enlarge 
the  wound  and  tie  the  vessel.  If  you  have  difficulty  in 
getting  at  it,  e.g.,  if  it  has  been  wounded  far  back 
in  the  chest,  you  must  resect  a  piece  of  rib ;  or,  better 
still,  loose  the  periosteum  ofif  the  rib,  and  thus  reach  the 
vessel.' 

Finally,  it  is  to  be  noted  that  aneurysm  of  the  vessel 
has  been  observed,  in  at  least  one  case,  after  wound  of  it. 

Wounds  of  the  Internal  Mammary  Arteries. 

We  have  here  to  consider  another  rare  injury,  seldom 
occurring  by  itself,  difficult  of  diagnosis,  very  difficult  of 

'  Riedinger,  loc.  cit.  p.  no. 


94 


SURGERY    OF    THE    CHEST. 


treatment,  and  usually  fatal.  The  depth  of  the  vessel, 
especially  in  the  lower  part  of  its  course,  and  its  position 
behind  a  barricade  of  costal  cartilages,  in  the  loose  tissue 
of  the  mediastinum,  close  to  the  pleura  and  the  peri- 
cardium, make  diagnosis  and  treatment  matters  of  almost 
insuperable  difficulty.  The  mediastinal  tissues,  the 
cavities  of  the  pleurae,  and  of  the  pericardium,  may 
one  or  all  of  them  be  the  seat  of  internal  haemorrhage ; 
the  soft  tissues  may  be  swollen  with  blood ;  and  they, 
and  the  costal  cartilages,  may  be  so  bruised  or  shattered, 
as  in  a  case  ot  gunshot  wound,  that  the  surgeon  may 
have  nothing  to  guide  him  to  the  artery,  and  cannot  be 
sure  that  it  is  the  source  of  the  haemorrhage. 

We  must  remember  that  any  incised  or  gunshot 
wound  near  the  border  of  the  sternum  must  be  very 
carefully  watched;  that  a  divided  costal  cartilage  may 
close  over  the  cut  artery,  and  direct  the  haemorrhage 
inward  ;  and  that  ligature  of  the  artery  is  fairly  easy 
in  the  second  and  third  spaces,  difficult  in  the  fourth, 
very  difficult  in  the  fifth,  and  almost  impracticable  in  the 
sixth.  '  The  operation  is  not  difficult  in  the  upper  inter- 
costal spaces,  except  in  those  cases  of  gunshot  fracture  in 
which  the  relations  of  the  parts  are  disturbed.  When 
there  is  an  open  wound,  when  the  adjacent  soft  tissues 
are  swollen  and  infiltrated,  and  the  vessel  lacerated 
and  displaced,  the  operation  becomes  very  difficult :  then 
it  is  best  to  have  recourse  to  compression.' 

In  the  literature  on  this  subject,  there  are  two  treatises 
of  especial  value.  One  is  on  the  '  History  of  the  American 
War,'  from  which  I  have  just  quoted.  In  the  records  of 
the  war,  there  are  only  five  or  six  cases  in  which  wounds 
of  the  internal  mammary  were  distinctly  recognized. 
Three  of  these  were  treated  by  compression  and  styptics, 
and   two  by  ligation.     '  But  there  are  many  other  re- 


WOUNDS    OF    THE   MAMMARY   ARTERIES.         95 

corded  instances  of  wounds  near  the  edge  of  the  sternum, 
with  haemorrhage  yet  without  haemoptysis,  in  some  of 
which  the  existence  of  this  lesion  may  fairly  be  suspected.' 
It  was  fatal  in  all  the  five  cases  in  which  it  was  clearly 
recognized.  In  three  cases  of  gunshot  wound,  with 
severe  laceration  of  the  tissues,  the  haemorrhage  was 
secondary;  in  one  on  the  14th,  one  on  the  37th,  and  one 
on  the  53rd  day  after  the  injury. 

Our  other  guide  to  the  study  of  this  subject  is  the 
admirable  essay  by  Tourdes.i  And  as  I  cannot  hope 
to  make  or  quote  any  clearer  rules  for  diagnosis  or 
treatment  than  those  which  each  of  us  may  make  for 
himself  by  reading  Tourdes'  collected  cases,  I  give  them 
in  full. 

1.  A  child,  falling  on  broken  glass,  cut  its  seventh  costal 
cartilage,  and  divided  the  external  branch  of  the  artery. 
The  pleura  was  not  opened.  Ligature  was  tried,  but  found 
impossible.  A  compress  was  applied.  Recovery,  after  ex- 
foliation of  cartilage. 

2.  A  soldier  received  a  sabre-wound,  which  divided  the 
seventh  right  costal  cartilage,  severed  the  artery,  and  opened 
the  pleura  and  the  pericardium,  but  did  not  injure  the  lung. 
Only  a  compress  was  used.  He  suffered  agonies  of  distress 
and  an  overwhelming  sense  of  oppression,  as  from  haemor- 
rhage into  the  pleura  and  pericardium.  Finally,  the  extra- 
vasation into  the  pleura  was  absorbed,  and  he  recovered. 

3.  A  soldier,  aged  30,  received  a  bayonet  wound,  a  mere 
puncture,  just  below  the  second  right  costal  cartilage,  close 
to  the  sternum.  Only  a  few  drops  of  blood  escaped,  and 
there  was  no  hEemoptysis.  He  at  once  suffered  a  frightful 
sense  of  oppression,  and  was  bled  thrice  in  forty-eight  hours. 
Then  signs  were  found  of  hfemorrhage  into  the  right  pleura  ; 
and  on  the  sixth  day  he  suffered  intense  dyspnoea,  and 
seemed  at  the  point  of  death.  An  incision  was  made  into 
the  pleura,  and  2  pints  of  blood  and  serum  were  let  out, 
to  his  great  relief.     He  slowly  recovered. 

4.  A   man    was    shot,    the    bullet  fracturing  the   fourth 

»  "  Annales  d'  Hygiene  Publique,"  Paris,  1849,  xlii.,  p.  165. 


96  SURGERY    OF    THE    CHEST. 

left  costal  cartilage  close  to  the  sternum,  and  lodging  in 
his  back,  whence  it  was  removed.  He  was  bled  repeatedly. 
On  the  third  day  there  was  severe  haemorrhage  from  the 
artery,  or  from  a  branch  of  it  ;  and  so  much  blood  was 
poured  into  the  pleura  that  on  the  fifth  day  he  was  near 
dying  of  suffocation.  He  was  put  face  downward,  and  a 
pint  of  broken-down  blood  flowed  from  his  wound  ;  and  this 
primitive  method  was  repeated  for  many  days.  On  the 
eighteenth  day  the  pleura  was  incised,  and  a  pint  of  foetid 
blood  was  let  out.  The  incision  was  kept  open,  and  sixteen 
weeks  after  he  was  shot  a  bit  of  his  shirt  was  removed 
through  it.     A  month  later  he  was  healed. 

5.  A  man,  aged  40,  was  stabbed  between  the  third  and 
fourth  right  costal  cartilages,  and  the  latter  was  divided.  The 
wound  bled  freely  ;  he  had  haemoptysis,  with  intense  dyspnoea 
and  prostration.  The  external  haemorrhage  ceased  of  itself 
Some  days  later  there  were  signs  of  fluid  in  the  right  pleura; 
on  paracentesis,  45  pints  of  foetid  blood  were  withdrawn. 
He  slowly  recovered. 

6.  A  man  was  shot,  the  ball  fracturing  the  third  and 
fourth  left  ribs,  lacerating  the  artery,  opening  the  pleura, 
and  just  grazing  the  lung.  He  died  in  forty-eight  hours,  and 
3^  pints  of  blood  were  found  in  the  pleural  cavity. 

7.  A  duellist  received  a  sword-wound,  which  entered  be- 
tween the  first  and  second  left  ribs,  close  to  the  sternum, 
and  wounded  the  artery,  the  lung,  and  the  intercostal 
artery  near  its  origin,  and  passed  out  between  the  second 
and  third  ribs  behind.  The  hjemorrhage  was  frightful. 
The  wounds  were  at  once  adjusted  and  closed.  Up  to 
the  eighth  day  he  improved  ;  then  a  change  for  the  worse  set 
in,  with  high  fever.  An  incision  into  the  pleura  let  out  sever.al 
pints  of  broken-down  blood.  Five  weeks  after  the  injury, 
his  wounds  front  and  back  were  healed  ;  the  discharge  Irom 
the  pleural  cavity  was  less  ;  the  chest-wall  was  falling  in. 
Nine  weeks  later  he  gave  himself  up  to  excesses  of  every 
kind  ;  lost  ground  slowly,  and  died  in  five  weeks,  or  134  days 
after  injury.  Fos^  mortem,  pleural  cavity  reduced  by  one- 
third  ;  pleura  and  pericardium  much  diseased  ;  sword- 
w'0'unds  healed;  divided  ends  of  the  artery  retracted  and 
obliterated. 

8.  A  man,  bent  on  suicide,  stabbed  himself,  cutting  the 
fifth  left  costal  cartilage  close  to  the  sternum  ;  bright  blood 
spurted  from  between  the  cut  edges  of  the  cartilage  ;  he  was 
much  collapsed,  and  there  were  signs  that  the  lung  and  the 
pericardium  were  involved.     The  wound  was  closed  at  once, 


WOUNDS    OF   THE    MAMMARY   ARTERIES.         97 

and  for  eight  days  he  was  now  better,  now  worse.  Then 
came  intense  pain  at  the  wound,  and  he  could  not  He  on  that 
side :  but  no  signs  of  pleural  effusion  were  found.  To  his  pain 
and  distress  were  added  wasting  and  diarrhcea  ;  and  as  the 
days  went  on,  it  was  noted  that  the  heart-impulse  felt  faint 
and  remote,  and  seemed  to  be  transmitted  through  fluid. 
On  the  forty-eighth  day,  therefore,  believing  that  he  had  to  deal 
with  a  large  haemorrhage  into  the  pericardium,  Larrey  cut 
clown  through  the  fifth  left  space,  just  below  the  nipple.  He 
let  out  serous  fluid,  mixed  with  blood-clot  ;  it  escaped  in  jets, 
in  time  with  the  heart,  and  he  thought  that  his  finger  touched 
the  apex  of  the  heart  itself  The  incision  suppurated  for  eight 
days,  and  then  closed  ;  then  the  patient's  troubles  returned, 
and  it  was  re-opened.  He  did  well  for  some  time,  hut  died 
exhausted  with  vomiting,  diarrhoea,  and  wasting,  on  the 
sixty-third  day.  Pos^  mortem.,  no  fluid  in  the  pleura  ;  lung 
adherent.  Occupying  the  whole  of  the  anterior  mediastinum, 
and  extending  back  toward  the  spine,  was  a  large  shut-off 
cavity,  its  walls  lined  with  dark  purulent  fibrinous  deposit  ; 
it  was  this  encysted  haemorrhage  that  had  been  taken  during 
life  for  the  cavity  of  the  pericardium.  The  pericardium  was 
adherent;  a  thin  clot  lay  over  the  right  ventricle;  there  were 
faint  traces  of  a  scar  of  the  pericardium  and  of  the  heart. 
The  arteiy  was  completely  divided. 

9.  A  man,  aged  26,  received  a  sabre-wound  between  the 
second  and  third  right  costal  cartilages,  near  the  sternum  ; 
bright  blood  poured  from  the  wound,  and  he  also  coughed  up 
blood.  The  wound  was  closed  ;  he  was  bled  ;  and  on  the 
sixth  day  the  heemoptysis  had  ceased,  the  wound  was  healing, 
and  he  was  doing  well.  On  the  eleventh  day  there  was  in- 
creased distress,  high  fever,  and  signs  of  pleural  effusion, 
which  was  allowed  to  remain  unrelieved.  On  the  thirty-first 
day  a  fluctuating  and  pulsating  swelling,  the  size  of  a  pigeon's 
egg,  was  observed  beneath  the  scar.  It  was  punctured,  but 
only  blood  came  out.  The  patient  sank  and  died  on  the 
thirty-seventh  day.  Post  mortem.,  a  "  chronic  pleurisy  "  of 
the  right  side,  containing  9  or  10  pints  of  serum  and  blood  ; 
the  lung  was  so  packed  against  the  spine  as  to  be  almost 
lost.  The  artery,  cut  half  across,  had  given  rise  to  a  small 
aneurysm. 

10.  A  man,  aged  22,  was  stabbed  over  the  third  left  costal 
cartilage  ;  he  became  pale  and  cold,  with  a  feeble  pulse, 
vomiting,  and  much  pain  at  the  wound  ;  he  could  not  lie  on 
the  sound  side.  The  surgeon  made  light  of  it,  only  bled  and 
leeched  him,  and  did  not  discover  till  the  fourth  day  that  the 

7 


98  SURGERY    OF    THE    CHEST. 

second  costal  cartilage  was  cut  clean  through.  On  the  sixth 
day,  came  a  profuse  discharge  of  pus  and  blood  from  the 
wound,  increased  pain,  dyspnoea,  and  hectic  lever.  Vene- 
section, calomel,  antimony,  etc.,  were  employed.  On  the 
sixteenth  day,  severe  dyspnoea,  intense  distress,  cedema  of 
the  chest-wall  ;  more  venesection  ;  leeches  ;  death  the  next 
day.  Post  morteni,  the  second  costal  cartilage  was  divided 
and  gaping  ;  the  pleura  had  been  opened,  and  contained  60 
or  70  ounces  of  pus  and  blood  ;  the  lung,  compressed  to 
one-sixth,  was  packed  against  the  spine.  The  artery  was 
cut  half  across. 

II.  A  man,  aged  30,  was  stabbed  several  times  in  the 
chest  and  abdomen.  One  of  the  wounds  divided  the  fifth 
right  costal  cartilage,  close  to  the  sternum  ;  severed  the 
artery  and  one  of  its  veins  ;  opened  the  pleura,  and 
just  grazed  the  lung.  The  wound  was  closed  at  once ; 
venesection  and  leeches  were  used  ;  he  died  in  twenty-four 
hours.  Post  ino7-tevi,  more  than  a  pint  of  blood-clot  in  the 
pleura  ;  and  the  lung,  not  wounded,  only  just  grazed,  was 
reduced  to  one-third  and  packed  against  the  spine. 

These  cases  show  clearly  the  difficulties  and  errors 
that  awaii  the  surgeon  who  is  called  to  treat  a  wound 
of  the  internal  mammary  artery.  Shall  he  venture  to 
trust  to  compression,  or  must  he  at  once  operate  ? 
Is  the  pleura  wounded,  and,  if  so,  does  the  blood 
come  from  the  lung,  or  the  artery,  or  both  ?  Is  there 
a  wound  of  the  pericardium  or  of  the  heart  ?  And  if 
he  must  operate  at  once,  what  is  the  best  method  to 
follow  ? 

His  immediate  diagnosis  depends  on  the  position  of 
the  wound, //?i;i' external  haemoiThage.  But  the  wound 
may  be  oblique,  or  the  cut  ends  of  the  cartilage  may  at 
once  come  together  again  ;  then  the  blood  will  flow  into 
the  pleura  ;  or,  if  the  pleura  be  intact,  into  the  medias- 
tinal space  ;  or,  if  the  pericardium  be  wounded,  into 
that  cavity.  But  blood  in  the  pleura  may  come  from  the 
lung ;  blood  in  the  pericardium  from  the  heart.  Again, 
the   external  bleeding  may  have  stopped  of  itself;   or 


HEMOTHORAX.  99 

there  may  be  room  for  doubt  whether  the  artery  really 
has  been  wounded  at  all.' 

But  since  a  partial  wound  of  the  artery  is  worse  than  a 
clean  division  of  it ;  since  the  absence  ot  external 
hseraorrhage  is  no  proof  that  the  artery  has  escaped 
injury ;  and  since  operation  is  in  accord  both  with 
the  principles  of  surgery,  and  with  the  teaching  of  those 
who  have  most  studied  the  subject,  the  surgeon  ought  to 
operate,  unless  there  be  some  good  reason  against  it. 
The  treatment  of  the  hccmorrhage  into  the  pleura  or  the 
pericardium — whether  by  incision,  or  by  the  promotion 
of  absorption — need  not  here  be  considered. 

The  method  of  operation,  as  taught  by  Goyrand,  is 
as  follows  :  The  incision,  near  the  edge  of  the  sternum, 
should  be  directed  outward  at  an  angle  of  45°  with  the 
middle  line.  Its  central  point,  over  the  intercostal  space 
where  the  artery  is  to  be  tied,  should  be  a  quarter  of  an 
inch  from  the  edge  of  the  sternum.  Skin,  subcutaneous 
tissue,  and  pectoral  muscle  having  been  divided,  the 
aponeurosis  of  the  external  intercostal  muscle  must  be 
cleanly  divided,  the  internal  intercostal  muscle  must  be 
scraped  through,  and  the  artery  will  then  be  found,  a 
quarter  of  an  inch  from  the  sternum. 

H^MOTHORAX.2 

Blood  may  be  poured  into  the  pleura  either  from  a 
wounded  intercostal  or  internal  mammary  artery,  or  from 

'■  Gurlt,  speaking  of  rupture  of  the  artery  in  fracture  of  the 
sternum,  says :  '  A  laceration  of  the  internal  mammary  artery, 
or  a  superficial,  not  immediately  fatal,  injury  of  the  heart,  cannot 
be  diagnosed  with  certainty ;  neither  the  symptoms  nor  the 
physical  signs  of  mediastinal  haemorrhage  are  definite  enough  to 
lead  us  to  any  certain  diagnosis.' 

^  In  addition  to  authorities  already  given,  see  Pagenstecher, 
"  Beitrage  z.  Klin.  Chir.,"  1895,  xiii.,  i,  264;  and  "  Semaine 
Mcdicale,"  1895,  Nov.  13th  and  20th. 


loo  SURGERY    OF    THE    CHEST. 

a  wound  of  the  lung,  the  heart,  the  diaphragm,  or  the 
great  blood-vessels.  We  have  not  here  to  consider  these 
various  injuries  or  their  treatment,  but  only  to  note  the 
signs  and  course  of  an  effusion  of  blood  into  the  pleura, 
and  the  treatment  that  it  may  itself  require,  apart  from 
the  wound  that  has  caused  it. 

Haemorrhage  into  the  pleura,  like  other  haemorrhages, 
may  be  primary  or  secondary  ;  it  may  be  so  furious,  as  in 
some  gunshot  wounds,  that  death  is  almost  immediate  ; 
if  it  be  not  fatal  at  once,  it  makes  itself  known,  in 
the  worst  cases,  in  a  few  hours,  by  all  the  signs  of 
rapid  and  exhausting  loss  of  blood,  plus  sudden  ever- 
growing compression  of  the  lung,  and  perhaps  also  dis- 
placement of  the  heart,  plus  the  physical  signs  of  a  mass 
of  fluid  in  the  pleura,  or  of  fluid  in  the  lower  part  of  it, 
with  air  above.  The  patient  is  restless,  distressed, 
oppressed,  unable  to  lie  down,  throwing  himself  into  one 
attitude  after  another,  fighting  for  his  life  ;  his  face  is 
blanched  and  sweaty,  his  lips  livid  ;  his  breathing  rapid, 
difficult,  and  laboured  ;  his  pulse  rapid,  small,  irregular ; 
he  may  know  from  his  own  sensations  that  he  is  bleeding 
inwardly,  and  blood  may  pour  from  the  wound  at  every 
cough  or  sudden  change  of  posture ;  his  hands  and  feet 
grow  cold,  he  has  giddiness,  noises  in  the  ears,  dimness 
of  vision,  faints,  becomes  unconscious,  and  dies. 

In  less  rapid  and  less  profuse  haemorrhage,  the  suffer- 
ing is  proportionally  less  acute,  and  the  surgeon  may 
even  venture  to  watch  the  case  without  at  once  inter- 
fering. In  these  instances  of  gradual  effusion,  from 
penetrating  wound  of  the  chest,  there  has  been  observed, 
in  some  few  cases,  oedema  or  ecchymosis  of  the  lumbar 
regions  ;  and  this  condition  was  held  by  Larrey  and 
others  to  be  an  important  indication  of  the  presence 
of  blood  in  the  pleural  cavity.     But  it  has  been  noted  in 


HEMOTHORAX.  loi 

cases  where  there  was  no  haemothorax  ;  and  is  usually 
absent  even  where  there  is  profuse  hsemothorax. 

Apart  from  injury,  hsemothorax  may  arise  from  aneu- 
rysm, from  malignant  disease,  or  from  ulceration  or 
erosion  of  tissues  in  tubercular  disease,  as  where  caries  of 
a  rib  causes  erosion  of  an  intercostal  artery.  In  such 
cases  the  onset  of  haemorrhage  is  usually  marked  by  severe 
pain,  followed  by  oppression,  dyspnoea,  and  other  symp- 
toms and  physical  signs  such  as  I  have  already  noted. 

The  course  and  treatment  of  haemothorax  after  injury 
have  been  considered,  to  some  extent,  in  the  foregoing 
pages.  We  have  now  to  consider  what  happens  to  blood 
effused  into  the  pleura  and  not  removed  from  it. 

Many  experiments  have  been  made  to  ascertain  the 
changes  which  occur  in  blood  left  undisturbed  in  the 
pleura.  Wintrich  (1854)  found  by  numerous  observa 
tions  on  rabbits,  dogs,  and  cats,  that  complete  absorption 
took  place  in  two  to  eight  days  without  leaving  even 
a  trace  of  pigmentation.  The  whole  subject  is  fully 
treated  by  Pagenstecher,  in  a  paper  published  last 
year,  and  his  results  are  worthy  of  careful  study.  His 
method  was  to  divert  blood,  by  means  of  a  simple  trans- 
fusion apparatus,  from  the  carotid  into  the  pleura  of  the 
same  animal.     I  give  five  of  his  observations  : — 

1.  In  a  rabbit,  blood  was  transfused  from  the  carotid  into 
the  pleura  for  the  space  of  two  minutes.  The  animal  was 
killed  two  hours  after.  The  lung  was  already  retracted  ;  in 
the  pleura  were  14  cub.  cm.  of  fluid  blood,  and  one  small  clot. 

2.  In  a  rabbit,  the  blood  was  transfused  till  the  pleura 
seemed  quite  full,  and  slight  convulsions  occurred.  The 
animal  diedyfe-^  hours  later.  The  pleura  was  occupied  by  11 
cub.  cm.  of  blood  clot,  and  5  cub.  cm.  of  fluid.  The  lung, 
though  compressed,  was  not  wholly  airless.  The  opposite 
lung  was  congested. 

3.  A  similar  experiment.  The  animal  died  within 
twenty-four  hours.     The  pleura  contained  a  huge  blood  clot, 


102  SURGERY    OF    THE    CHEST. 

lying  over  the  lung,  together  with  lo  cub.  cm.  of  fluid. 
There  was  still  some  air  in  the  lung  :  the  lower  lobe  of  it  was 
ecchymosed. 

4.  A  dog  was  transfused,  by  the  same  method,  for  two- 
and-a-half  minutes.  He  was  killed  ai  the  e7id  of  twenty -four 
hows.  There  was  no  fluid  in  the  pleura  :  only  a  large  non- 
adherent clot  of  great  size.  There  was  no  sign  of  irritation 
of  the  pleura. 

5.  A  dog  was  transfused  until  there  were  signs  of 
dyspnoea.  He  was  killed  07t  the  seventeenth  day.  The  lung 
was  found  adherent  to  the  chest  wall  and  to  the  diaphragm 
by  fine  firm  adhesions,  in  which  was  enclosed  some  altered 
blood  clot  ;  the  pleural  cavity  was  contracted  ;  the  lung  con- 
tained ail'.     The  opposite  lung  was  somewhat  congested. 

From  these  experiments  alone  it  would  seem  that 
blood,  effused  into  the  pleura,  becomes  coagulated  in  a 
few  hours.  But  careful  analysis  of  the  fluid  and  of  the 
clots  showed  that  their  composition  was  slightly  different 
from  that  of  ordinary  serum  and  blood-clot.  And,  from 
the  following  case,  Pagenstecher  believes  that  the 
changes  in  hsemothorax  are  of  a  special  character, 
akin  to  the  changes  which  occur  in  thrombosis  in  a  vein: 
and  that  they  depend  on  a  damaged  state  of  the  pleura. 

A  man  was  severely  crushed  in  a  railway  accident,  and 
died  three  hours  after  it.  Blood  drawn  from  the  pleura  four- 
and-a-half  hours  after  death,  while  the  body  was  still  warm, 
was  still  fluid,  dark,  and  unmixed  with  clot ;  and  it  remained 
fluid  even  after  several  days'  exposure  to  the  air,  forming  an 
upper  layer  of  clear  reddish  serum,  and  a  lower  dark  layer  of 
red  blood-corpuscles.  Post  niorienij  there  was  a  large  hole 
in  the  chest-wall,  from  which  blood  was  flowing  and  the  lung" 
was  protruding.  In  the  pleura  there  were  nearly  two  quarts 
of  dark  fluid  blood,  but  no  trace  of  any  clot.  The  lung  was 
compressed,  but  not  lacerated.  There  were  clots  in  a 
haemorrhage  in  the  anterior  mediastinum. 

It  appears  therefore  that  the  pleura  can  keep  the  blood 
in  it  fluid,  but  still  not  ttnaltered  ;  and  that  the  process 
of  coagulation  may  be  compared  to  the  process  of  throm- 
bosis inside  a  blood-vessel.      Absorption  is,  as  a  rule, 


H/EMOTHORAX.  103 

very  rapid.  In  the  first  of  Pagenstecher's  experiments, 
the  lymph-spaces  of  the  pleura  covering  the  diaphragm 
were  already  dilated,  and  contained  whole  or  broken  red 
blood  corpuscles.  Wisner  injected  olive-oil  into  the 
pleurae  of  animals,  and  four  hours  later  found  minute 
emboli  of  oil  in  the  lungs.  But  of  course,  in  any  patient, 
the  work  of  absorption  may  be  retarded  by  old  pleural 
adhesions,  or  by  a  state  of  shock. 

There  is  no  evidence  that  the  presence  of  blood  in 
the  pleura  causes  reactionary  effusion  of  pleural  fluid. 
Pagenstecher,  in  one  of  his  transfusion  experiments,  also 
injected  some  atropine  under  the  animal's  skin.  He  drew 
off  some  of  the  transfused  blood  two  hours  after  the  opera- 
tion, and  again  four  hours  after,  and  killed  the  animal 
eighteen  hours  after  it,  and  collected  the  rest  of  the 
blood.  None  of  the  three  specimens  thus  obtained 
showed  the  least  admixture  of  atropine. 

Nor  is  there  anything  to  show  that  the  pleuritic  or 
purulent  effusions,  which  so  often  follow  haemothorax, 
are  due  to  direct  irritation  of  the  pleura  by  the  blood 
contained  in  it.  Probably,  in  these  cases,  the  pleura  is 
injured  or  infected  at  the  time  of  the  accident.  This 
pleural  effusion,  marked  by  fever  and  by  increase  of 
dulness,  without  any  symptom  of  renewed  loss  of  blood, 
may  occur  at  any  time  after  the  first  twenty-four  hours  ; 
and  Wintrich  has  recorded  a  case  where  it  occurred 
as  late  as  the  sixteenth  day.  If  it  be  not  purulent,  it 
usually  disappears  without  surgical  treatment. 

But  it  is  to  be  observed  that  this  effusion  after  h^emo- 
thorax  does  not  always  behave  like  a  common  pleural 
effusion  ;  it  follows  an  unusual  set  of  conditions,  and  is 
likely  to  run  a  course  of  its  own.     Tuffier  ^  has  lately 

'"  Semaine  Medicale,"  Nov.  20th,  1895. 


I04  SURGERY    OF    THE    CHEST. 

called  attention  to  the  difficulty  of  knowing  when  to 
interfere  in  these  irregular  and  uncertain  cases  of  pleural 
effusion  after  hsemothorax.  He  gives  three  from  his  own 
experience,  illustrating  their  tendency  to  deviate  from  a 
regular  course.  In  the  lirst  case,  a  student,  aged  20, 
■shot  himself  in  the  left  side  of  the  chest,  and  the  injury 
Avas  followed  by  hsemothorax.  On  the  third  day  he 
became  feverish  ;  on  the  fourth,  his  temperature  rose 
to  104,  and  Tuffier  punctured  the  chest,  but  drew  off  only 
a  few  drops  of  fluid,  which,  on  testing,  were  found 
perfectly  sterile.  Nothing  further  was  done  ;  the  patient 
made  a  complete  recovery.  In  the  second  case,  a  girl, 
aged  18,  shot  herself  in  the  right  side  of  the  chest,  and 
the  injury  was  followed  by  hsemothorax.  On  the  sixth 
day  she  became  feverish,  and  her  temperature  rose  above 
103.  Nothing  was  done  ;  complete  absorption  followed 
without  further  trouble.  The  third  case  was  like  the 
other  two,  except  that  the  rise  of  temperature  did  not 
occur  till  the  eighth  day.  Nothing  was  done  ;  complete 
absorption  followed,  and  the  patient  made  a  good 
recovery. 

We  must  remember  that  in  cases  of  injury  there  is 
usually  air,  as  well  as  blood,  in  the  pleura,  leading  us  to 
anticipate  a  tendency  to  suppuration. 

Something  has  already  been  said  about  the  treatment 
of  hsemothorax,  but  a  few  points  remain  for  consideration. 
First,  unless  there  be  signs  of  serious  or  increasing  pres- 
sure on  the  lung,  the  surgeon  should  hold  his  hand, 
in  the  belief  that  the  blood  will  be  absorbed  and  turned 
to  good  account,  instead  of  being  lost  by  withdrawal 
from  the  body.  Next,  if  he  must  operate,  he  should  be 
prepared  to  transfuse  the  patient  immediately  after 
operation.  And,  if  the  aspirator  fails  to  give  relief 
because  it  gets  blocked  with   clot,  he  must  incise  the 


HJEMO  THORA  X.  105 

chest.  Finally,  he  must  not  attempt  to  withdraw  all  the 
blood  at  once,  lest  he  excite  fresh  haemorrhage.  Not  that 
the  original  hemorrhage  is  stopped  by.  the  actual  pressure 
of  the  effused  blood  on  the  bleeding  point :  this  could 
not  happen  unless  the  whole  side  of  the  chest  were  loaded 
with  a  huge  effusion  under  high  pressure  :  but  lest  a  too 
vigorous  use  of  the  aspirator  should  loosen  some  wound 
in  the  lung  just  healed. 


io6 


CHAPTER    IX. 

WOUNDS     OF    THE    LUNG. 

The  way  is  now  cleared  for  consideration  of  the  chief 
facts  in  wounds  of  the  lung  ;  but  the  subject  is  so  great 
that  we  cannot  hope  to  see  all  sides  of  it,  and  many 
pages  might  be  given  to  treatment  alone,  in  view  of  the 
work  of  the  last  few  years.  It  may  be  convenient  to 
consider  first  the  general  difficulties  of  dealing  with  a 
wounded  lung ;  next  the  usual  character  and  course  of 
such  wounds  ;  and  then  the  limits  and  possibilities  of 
treatment. 

In  the  first  place,  the  case  has  probably  a  medico-legal 
side  to  it.  Hence,  the  surgeon  must  lose  no  time  in 
noting  carefully  the  whole  scene,  the  position  and  con- 
dition of  the  patient,  the  shape,  size,  and  staining  of  the 
weapon,  and  the  exact  character  and  measurement  of 
the  wound.  Before  any  further  steps  are  decided  upon, 
external  haemorrhage,  if  present,  must  be  checiced,  at 
least  temporarily,  by  firm  pressure ;  and  the  worst  of  the 
shock  must  be  overcome  with  warmth  to  the  extremities, 
hypodermics  of  strychnine,  and  careful  stimulation. 

Next,  the  difficulty  of  examination  is  much  increased 
by  the  necessity  for  absolute  and  complete  rest — - 
^immobilM  absobie,'  the  forbidding  of  all  movement,  the 
scrupulous  avoidance  of  all  handling  of  the  patient,  that  is 
not  really  necessary.  What  Rose^  says  of  wounds  in  the 
region  of  the  heart  applies,  almost  as  strictly,  to  the  lung. 

'"  Herztamponade :  ein  Beitrag  zur  Herzchirurgis  " ;  "  Deutsche 
Ztschr.  f.  Chir.,"  1884,  xx. ,  329. 


WOUNDS    OF    THE    LUNG.  107 

"  Certainly  the  worst  thing  of  all  for  the  patient  is 
'thorough  examination.'  We  have  got  past  that  bad  time 
in  surgery,  when  a  man  would  not  leave  a  fractured  pelvis 
alone  till  he  had  made  it  crack,  or,  as  he  called  it  to  pacify 
the  patient,  till  he  had  established  beyond  doubt  the 
presence  of  crepitation.  Why  should  we  treat  cases  of 
internal  wound  or  injury  worse  than-  we  now  treat  a 
fractured  pelvis  ?  In  all  such  cases,  I  avoid  all  repeated 
examinations;  I  make  the  examination  with  all  gentleness; 
I  never  probe  the  wound  or  put  my  finger  in  it.  I  percuss 
the  patient  softly,  do  not  ask  him  to  breathe  hard  during 
auscultation,  and  prefer  not  to  listen  to  his  back,  rather 
than  set  him  up  in  bed  without  some  special  reason,  or 
disturb  by  any  movement  the  delicate  half-formed 
adhesions,  which  are  our  chief  hope  of  his  recovery.  But 
there  are  still  cases  where,  in  spite  of  all  my  warnings  and 
orders,  these  rules  are  broken,  and  the  excessive  zeal 
of  some  of  my  assistants  for  accurate  diagnosis  has 
retarded  healing  and  brought  the  patient  into  grave  danger 
of  death." 

The  two  following  cases  bring  out  this  point ^  : — 

1.  A  young  man,  while  fencing,  was  wounded  near  the 
right  axilla  with  a  foil  without  a  button  ;  he  began  to  cough 
blood  very  freely  at  once,  even  before  he  could  take  off  his 
mask.  He  was  immediately  laid  flat,  forbidden  to  move,  to 
make  any  effort  to  clear  his  throat,  or  even  to  take  a  stimu- 
lant. Three  hours  later,  a  little  iced  champagne  was  given  ; 
low  diet  ;  a  purge  on  the  third  day.  The  haemoptysis  did 
not  recur  ;  an  effusion  into  the  pleura,  probably  blood,  was 
slowly  absorbed.  He  was  kept  at  the  gymnasium  for  six 
weeks  before  he  was  allowed  to  leave  his  bed  and  go  home. 
Complete  recovery. 

2.  A  young  man,  in  a  duel,  received  a  thrust  under  the 
pectoralis  major  in  the  third  right  intercostal  space.     The 

'"De  rimmobilite  absolue  du  blesse  comme  condition  essentielle 
du  traitementdes  plaies  penetrantes  de  poitrine  par  arme blanche," 
"  Semaine  Medicale,"  Feb.  6th,  1895. 


io8  SURGERY    OF    THE    CHEST. 

sword  was  stained  with  blood  for  more  than  a  third  of  its 
length.  He  was  removed  a  long  journey  to  Hospital,  repeated 
injections  of  ether  andofergotin  being  made  on  the  way. 
He  was  not  got  to  bed  till  two  hours  after  the  accident  ;  then 
he  was  stripped,  and  a  prolonged  examination  and  dressing 
of  the  wound  were  made.  In  a  very  short  time,  a  frightful 
hccmorrhage  came  from  his  mouth,  and  he  died.  Posi  )nor- 
fe»i,  there  was  a  wound  of  the  whole  depth  of  the  lung,  but 
no  great  vessel  had  been  divided. 

The  contrast  between  these  two  cases  suggests  to  us 
that  one  thus  wounded  should  be  kept  flat,  not  raised  for 
auscultation,  forbidden  to  move,  to  speak,  even,  if  he  can 
help  it,  to  cough  or  clear  his  mouth.  His  clothes  should 
be  cut  off,  not  taken  off.  All  food  must  at  first  be  withheld. 
The  wound  must  be  dressed  without  moving  him,  so  far 
as  possible. 

But  even  if  the  surgeon  is  prevented  by  the  critical 
condition  of  the  patient  from  making  a  thorough 
examination  of  the  wound,  and  from  complete  ausculta- 
tion and  percussion  of  the  chest,  he  has  other  evidence 
to  guide  him  as  to  the  probable  depth  of  the  wound  and 
the  extent  of  the  harm  done  to  the  lung.  Concerning 
emphysema  and  pneumothorax,  something  has  already 
been  said.  The  presence  of  either  or  both  does  not 
prove  that  the  lung  has  been  wounded.  The  pleura 
can  be  opened,  and  yet  the  lung  escape  ;  a  bullet  may 
be  deflected  from  it  by  a  rib,  or  an  incised  wound  may 
be  so  oblique  as  to  open  the  pleura  and  yet  barely  graze 
the  lung  ;  or  the  weapon,  e.g,  a  billhook  or  a  scythe', 
may  be  blunt  of  one  edge  and  curved,  thus  pushing  the 
lung  aside  without  cutting  it.     Or  the  injury  of  the  lung 

*  In  "  Casper's  Forensic  Medicine,"  i860  (Syd.  Soc.  Trans!.), 
i.,  165,  there  is  a  case  of  a  scythe-wound,  8  inches  long,  opening 
the  pleura,  but  not  wounding  the  lung.  And  the  two  famous 
cases  of  a  carriage-pole,  and  of  a  mast-end,  passing  through  the 
chest  without  causing  death,  are  also  instances  of  the  lungs  being 
thrust  aside  but  not  lacerated. 


WOUNDS    OF    THE    LUNG.  109 

may  be  too  slight  to  cause  symptoms  during  life,  or  to 
leave  a  scar  after  death. 

We  have  to  consider  here  those  wounds  that  afford  clear 
evidence  of  lung  injury  ;  and  this  evidence  is  haemorrhage, 
external  through  the  wound,  effused  into  the  pleural 
cavity,  running  into  the  bronchi,  escaping  through  the 
mouth  ;  the  signs  of  loss  of  blood — pallor,  bloodless 
tint  of  the  lips,  faintness,  quick  feeble  pulse,  hurried 
sighing  respiration,  cold  hands  and  feet,  and  marked 
restless  oppression  and  sense  of  impending  dissolution  ; 
and  the  physical  signs  of  effusion. 

Rapid  effusion  of  air  into  the  pleura  may  give  signs 
not  unlike  these  ;  but  it  has  also  distinctive  signs  of  its 
own.  The  effusion  of  both  air  and  blood  together  may 
confuse  the  picture,  but  does  not  wholly  prevent  the 
surgeon  from  estimating  the  source  and  extent  of  the 
bleeding.  Let  us  then  take  by  itself  the  haemorrhage 
from  wounds  of  the  lung;  excluding  haemorrhage  from 
the  heart  and  the  great  vessels. 

HEMOPTYSIS. 

There  are  many  ways  in  which  we  may  fail  to  estimate 

haemoptysis  aright.     It  may  follow  a  blow  on  the  chest, 

whereby  the  lung   is   concussed  or  contused,   but   not 

lacerated  ;  as  we  have  seen  in  the  chapter  on  fracture 

of  the  ribs. 

A  young-  man,  aged  21,  a  tall,  slender  recruit,  was 
accidentally  struck  on  the  left  side  by  one  of  his  com- 
rades. This  was  followed  by  copious  haemoptysis.  There 
was  no  fracture.  Large  moist  crepitations  were  heard  on 
auscultation.  He  continued  to  cough  up  blood,  at  intervals, 
for  three  days,  and  then  rapidly  recovered/ 

Or  it  may  follow  a  gunshot  wound,  where  the  bullet, 
'  "  Hist.  Amer.  War,"  pt.  i.,  Surg.  Vol.,  p.  637. 


no  SURGERY    OF    THE    CHEST. 

having  pierced  the  pleura,   has  been  deflected  by  a  rib, 
grazing  the  lung,  but  not  wounding  it. 

'  I  have  traced  a  ball  by  dissection,  passing  into  the 
cavity  of  the  thorax,  making  the  circuit  of  the  lung,  pene- 
trating nearly  opposite  the  point  of  entrance,  and  giving 
the  appearance  of  the  man  having  been  shot  fairly  across, 
while  bloody  sputa  seemed  to  prove  the  fact.  The  bloody 
sputa,  however,  were  only  secondary,  and  neither  so  active 
nor  alarming  as  those  which  pour  at  once  from  the  lung 
when  wounded.'  ^ 

Or  it  may  come  from  an  unsuspected  phthisical  cavity 
in  the  lung,  as  in  a  case  recorded  by  Dr.  Cayley,-  of 
a  police  constable,  aged  20,  '  always  strong  and 
healthy,'  who,  a  few  hours  after  receiving  a  violent  blow 
on  the  right  side  of  the  chest,  had  a  profuse  haemoptysis ; 
and  then,  for  the  first  time,  there  were  found  signs  of 
tuberculous  disease  of  the  right  apex.  Or  it  may  be  due 
to  some  trivial  wound  or  sore  in  the  mouth  or  upper  air 
passages  ;  as  in  a  case  lately  under  my  care,  a  young 
man  run  over,  whose  hjemoptysis  came  simply  from  some 
raw  patches  at  the  back  of  the  throat.  Nor  must  we 
forget  that  the  account  of  hsemoptysis  given  by  the  patient 
himself  is  generally  exaggerated  ;  and  that  it  is  a  common 
trick  of  malingerers. 

The  absence  of  haemoptysis  gives  us  no  assurance  that 
the  lung  has  not  been  wounded.  This  is  especially 
true  of  gunshot  wounds,  which  tear  or  break  the  lung, 
but  do  not  make  a  clean  cut  into  it.  And  cases  have 
been  given  (chap,  iv.)  of  extensive  laceration  of  the  lungs 
from  crushing  of  the  chest,  in  which  there  was  no  haemo- 
ptysis. In  St.  George's  Hospital  Museum,  there  is  a 
specimen  of  laceration  of  the  lung,  four  inches  long  and 
two  deep,  but  no  hsemoptysis  followed  it.     Of  the  cases 

'  Hennen,   "  Principles  of  Military  Surgery,"   1S29,  p.  372. 
-"Clin.  See.  Trans.,"  1874,  vii.,  p.  89. 


WOUNDS    OF    THE    LUNG.  iii 

of  gunshot  wound  of  the  chest  carefully  observed  in  the 
Crimean  War  by  Dr.  Fraser,  only  one  out  of  nine  fatal 
with  wound  of  the  lung  had  haemoptysis,  but  of  seven 
fatal  cases,  in  which  the  lung  was  not  wounded,  two  had 
it,  and  of  twelve  not  fatal,  three.  Out  of  8,715  pene- 
trating gunshot  wounds  in  the  American  War,  hemoptysis 
was  noted  in  492,  only  5^  per  cent.  ;  but  probably  in 
many  other  cases   it  occurred,  and  was  not  recorded. 

We  cannot,  therefore,  form  any  very  sure  conclu- 
sions as  to  the  state  of  the  lung  from  the  presence  or 
absence  of  haemoptysis  alone  ;  at  least,  so  far  as  gunshot 
wounds  are  concerned.  But  if  it  be  somewhat  profuse 
and  persistent,  and  apt  to  be  increased  by  the  coughing 
or  sudden  movement  or  exertion  of  the  patient,  and  if 
the  blood  be  frothy  with  air,  and  come  soon  after  the 
injury,  we  may  be  practically  certain  that  the  lung  has 
been  wounded. 

H/EMORRHAGE    INTO    PlEURA. 

Next,  as  to  haemorrhage  mto  the  pleural  cavity,  this 
may  be  either  primary  or  secondary,  rapid  or  slow.  The 
symptoms  of  internal  hasmorrhage,  the  physical  signs  of  a 
large  effusion  of  fluid  in  the  pleura,  or  of  fluid  below  and 
air  above,  may  be  present  almost  at  once,  or  may  gradually 
grow  more  marked  till  the  patient  is  at  the  point  of  death  ; 
or  may  reach  to  some  height,  and  then,  under  treatment, 
may  improve.  The  following  cases^  are  good  instances 
of  the  worst  sort  of  internal  hsemorrhage  into  the  pleura 
without  marked  external  hsemorrhage  : — 

I.  A  boy,  aged  14,  was  stabbed  in  the  back  with  a 
knife  ;  a  few  minutes  afterward,  he  fell  fainting  on  the  floor  ; 


'  Casper,  loc.  cit.  i.,  p.  122  :  and  Quenu,  "  Semaine  Med. 
Nov.  13th,  1895. 


112      ■  SURGERY    OF    THE    CHEST. 

he  died  in  six  hours.  Post  mortem,  the  wound  was  small, 
clean,  soft,  dry,  free  from  any  trace  of  ecchymosis,  "  just  such 
edges  as  would  have  existed  in  a  wound  made  on  a  dead 
body."  The  knife  had  gone  an  inch  and  a  half  deep  into  the 
lung,  and  in  the  pleura  were  4  pounds  of  dark  fluid  blood, 
with  some  coagula. 

2.  A  man  was  stabbed  in  the  second  right  intercostal 
space,  far  back,  near  the  inner  border  of  the  scapula,  and 
died  in  three-quarters  of  an  hour.  Post  mot-tern,  the  wound 
was  small,  clean,  smooth,  dry,  white,  wholly  without  ecchy- 
mosis. The  upper  lobe  of  the  lung  was  perforated,  and  in 
the  pleura  were  a  quart  and  a  half  of  dark  fluid  blood,  partly 
coagulated. 

3.  A  young  man,  aged  19,  was  admitted  to  Hospital 
with  a  penetrating  wound  of  the  seventh  left  intercostal 
space.  It  was  sutured  by  the  house-surgeon  on  duty.  '  I 
saw  him  next  morning,  and  was  struck  by  his  extreine  pallor, 
and  found  all  the  signs  of  a  large  pleural  effusion.  I  punc- 
tured the  chest,  and  drew  otf  18  ounces  of  almost  pure 
blood.  A  week  later,  I  again  punctured  him,  and  drew  off 
more  than  3  pints,  almost  all  blood.  Next  day,  in  view 
of  the  persistent  gravity  of  his  symptoms,  I  cut  the  stitches, 
enlarged  the  wound,  resected  the  seventh  rib,  and  having 
ascertained  that  the  bleeding  did  not  come  from  the  inter- 
costal artery,  I  made  a  free  incision  through  the  pleura,  and 
found  the  lung  retracted  far  back  against  the  spine.  I  turned 
out  several  clots  from  the  neighbourhood  of  the  wound  of  the 
lung,  and  put  in  a  plug  of  iodoform  gauze.  No  more 
haemorrhage  occurred  ;  the  cavity  filled  up  very  quickly,  and 
the  patient  was  discharged  in  a  fortnight.' 

It  is  the  same  internal  haemorrhage,  in  gunshot  wounds, 
that  accounts  for  a  great  number  of  deaths  on  the  field 
of  battle  :  as  Riedinger  describes  them  : — '  Many,  the 
moment  they  are  shot,  fall  and  give  no  further  sign  of 
life ;  many  are  left  for  dead  on  the  field,  yet  revive  ;  the 
wounded  are  pale  and  wretched,  their  lips  livid,  foreheads 
covered  with  sweat ;  they  suffer  pain  in  the  chest,  cough, 
faintness,  vomiting  ;  their  breathing  is  shallow,  rapid,  and 
difficult  ;  some  are  restless,  others  lie  unable  to  move  ; 
convulsions,  obscuration  of  vision,  excitement,  may  be 
noted.'     The  mortality  from   such  wounds,  in   time  of 


WOUNDS    OF    THE    LUNG.  113 

war,  is  probably  not  less  than  60  per  cent,  of  all 
chest-wounds  classed  as  penetrating,  and  much  higher 
than  this  for  actual  gunshot  wounds  into  the  lung.  After 
Sedan,  Sir  William  McCormac  reported  that  of  54  cases 
treated  at  the  Anglo-American  x\mbulance  at  Asfeld,  31 
were  regarded  as  penetrating,  of  which  17  died.  From 
Metz,  Dr.  Fischer  reported  78  cases,  of  which  34  were 
perforating  gunshot  wounds;  of  these  34,  19  died.  From 
Strasburg,  Dr.  Beck  reported  that  out  of  98  fatal  gunshot 
wounds  of  the  chest,  24  deaths  were  due  to  haemorrhage 
alone. 

HAEMORRHAGE    FROM    THE    WoUND. 

Finally,  we  have  to  consider  external  haemorrhage. 
Going  from  without  inward,  we  must  first  note  that 
bleeding  may  possibly  come  from  a  severed  vessel  outside 
the  ribs  ;  the  long  thoracic,  or  the  subscapular  artery, 
may  be  wounded ;  but  such  injuries  are  very  rare. 
Wounds  of  the  intercostal  and  internal  mammary  vessels 
have  already  been  discussed.  A  wounded  intercostal 
artery  may  bleed  profusely  into  the  pleura,  with  no 
marked  external  bleeding.  By  what  signs,  then,  may  we 
know,  from  the  external  wound,  whether  the  lung  itself  is 
bleeding  ?  The  passage  of  air  in  and  out  of  the  chest, 
or  its  being  forced  out  on  coughing,  the  'characteristic 
mucous  bubbling,'  is  no  sure  sign.  It  is  usually  absent, 
especially  when  the  external  wound  is  large ;  and  when 
present,  the  air  may  yet  be  driven  in  and  out  from  the 
soft  tissues  (emphysema)  or  from  the  pleura,  and  not 
come  from  the  lung  at  all.  If  we  can,  from  the  position 
and  direction  of  the  wound,  exclude  all  probability  that 
an  intercostal  or  internal  mammary  artery  has  been 
divided;  if  other  signs  of  wounded  lung  are  present,  and 
blood  is   collecting  in  the  pleura,  and  running  from  the 

8 


114  SURGERY    OF    THE    CHEST. 

wound  when  the  patient  coughs  or  struggles,  we  may  feel 
sure  that  it  comes  from  the  lung  itself,  especially  if  the 
finger,  passed  into  the  wound,  feel  no  jet  of  blood  from 
the  neighbourhood  of  the  intercostal  artery. 

General  Treatment  of  Wounds  of  the  Lung. 

Difficult  indeed  is  the  treatment  of  these  cases — 'a 
mighty  maze,  but  not  without  a  plan.'  Watching  the 
case  from  hour  to  hour,  what  indications  for  treatment 
may  we  hope  to  observe  ?  Too  great  stress  cannot  be 
laid  upon  the  necessity  of  staying  with  the  patient  and 
watching  him  closely. 

The  immediate  duty  of  the  surgeon,  to  check  the 
external  bleeding,  and  to  tide  over  the  worst  of  the  shock, 
has  already  been  discussed. 

As  regards  the  use  of  the  probe  there  is  some  difference 
of  opinion. 

It  is  easy  work  to  collect  warnings  against  its  use. 
In  an  incised  or  punctured  wound  it  is  better  not  to  use  it.^ 
It  is  in  gunshot  wounds  that  the  probe  may  be  needed, 
but  perhaps  not  at  first.     And  even  here,  as  we  see  from 

'  In  such  cases  it  may  do  positive  harm,  even  if  the 
information  it  gives  is  correct,  and  this  is  not  always  the  case. 
The  following  case  illustrates  this  point : — A  prisoner  in  the 
American  war  was  wounded  by  a  sentinel  with  a  bayonet  in  the 
right  side  of  the  chest,  four  inches  from  the  spine  and  two  inches 
below  the  angle  of  the  scapula.  ' '  On  examination  with  the  probe, 
I  found  that  the  probe  ran  down  beneath  the  skin  for  two  or  three 
inches,  but  was  unable  to  detect  any  opening  into  the  thorax.  .  . 
After  a  consultation,  it  was  concluded  that  it  was  a  non-penetra- 
ting wound  of  the  chest.  .  .  .  Toward  morning  he  became 
delirious,  and  died  about  sunrise."  Post  mortem,  the  whole  pleura 
was  full  of  blood  ;  the  lungs  were  not  injured  ;  the  bayonet  had 
penetrated  the  heart  (posterior  aspect  of  left  ventricle),  and  had 
probably  also  wounded  the  vena  cava  inferior. 

An  instance  of  harm  done  by  probing  a  knife-wound  is  given 
on  page  74. 


WOUNDS    OF    THE    LUNG.  115 

the  case^  reported  by  M.  Pean,  at  the  Surgical  Congress 
last  year  at  Paris,  its  use  may  lead  to  bad  results,  even 
when  there  is  reason  to  hope  that  the  bullet  is  not  out  of 
reach.  Authorities  indeed  are  by  no  means  agreed 
among  themselves  on  the  point.  Thus,  in  opposition  to 
Dupuytren,  Pirogoff,  Gross,  Erichsen,  and  others,  we 
find  Demme  saying  that  the  fear  of  a  careful  examination 
is  entirely  unfounded;  while  Legouest  maintains  that 
Dupuytren's  teaching  is  not  in  accord  with  the  facts 
of  the  case  ;  the  worst  that  can  happen,  in  probing  for  a 
bullet,  is  to  fail  to  find  it ;  the  lung  is  either  retracted 
out  of  reach  of  the  probe,  or  adherent  to  the  pleura,  so 
that  the  probe  will  keep  in  the  track  of  the  bullet  and  do 
no  more  harm  than  has  already  been  done.  From  the 
records  of  military  surgery,  and  the  teaching  of  most 
authorities,  we  may  fairly  conclude  that  its  careful  use, 
after  the  first  day  or  two,  is  in  some  cases  advisable. 
'  The  surgeon  will  gain  all  the  information  he  can  from 
observing  the  external  wound,  using  his  finger,  as  far  as 
he  judges  prudent,  to  determine  the  extent  of  the  wound 
and  the  presence  or  absence  of  foreign  bodies,  but  not 
employing  the  probe  in  early  examinations.  .  .  . 
There  is  a  wide  difference  between  rash  and  unwarrantable 


^  The  following  case  is  given  by  him.  A  man,  aged  45, 
a  drunkard,  shot  himself  with  a  revolver  over  the  heart,  in 
the  fifth  left  space.  The  injury  was  followed  by  dyspnoea 
and  haemoptysis  ;  the  heart-sounds  could  hardly  be  heard,  and 
there  was  extensive  dulness  over  the  base  of  the  left  lung.  "  In 
spite  of  these  alarming  symptoms,  and  of  an  extensive  pleurisy, 
he  quickly  improved,  and  his  recovery  seemed  certain,  till,  in 
disregard  of  my  directions,  one  of  our  house-surgeons  took  it 
into  his  head  to  remove  the  bullet,  which  could  be  easily  felt 
lying  near  the  sixth  dorsal  vertebra.  In  spite  of  the  strictest 
use  of  antiseptic  dressings,  a  phlegmonous  inflammation  appeared 
next  day  round  his  incision,  the  effusion  in  the  left  pleura  became 
purulent,  a  purulent  effusion  occurred  in  the  right  pleura ;  and 
all  our  endeavours  failed  to  save  the  patient's  life." 


ii6  SURGERY    OF    THE    CHEST. 

explorations,  and  the  judicious  use  of  the  probe  and 
forceps  in  cases  in  which  there  are  just  grounds  for 
suspecting  the  presence  of  a  foreign  body ;  and  the 
sagacious  practitioner  will  neither  discard  the  probe 
absolutely  nor  use  it  habitually.  It  is  almost  needless 
to  repeat  that  all  good  surgeons  agree  that  the  finger  is 
the  best  probe  whenever  available.' 

Having  thus,  as  it  were,  got  our  patient  over  the  first 
shock,  checked  the  external  haemorrhage,  and  so  far  as 
permissible  examined  the  wound,  other  questions  arise. 
How  shall  we  dress  the  wound  ?  Of  the  old  'hermetical 
sealing '  of  the  wound,  there  is  nothing  favourable  to  be 
said;  it  received  full  trial,  and  was  found  to  be  a  mistake. 
A  clean-cut  incised  wound  should  be  closed  ;  this  will 
prevent,  perhaps,  the  occurrence  of  pneumothorax  and 
collapse  of  the  lung ;  and  to  leave  the  wound  open  will 
not  prevent  emphysema.  And  the  chest  must  be  so  far 
as  possible  immobilized  with  a  carefully  adjusted  broad 
bandage,  or  a  binder  of  flannel  fastened  down  the  front. 
In  gunshot  wounds,  a  long  strip  of  iodoform  gauze, 
gently  pressed  into  the  wound,  will  prove  as  good  as  any 
other  first  dressing. 

Of  the  absolute  necessity  of  rest  I  have  already  spoken. 
In  most  cases  it  will  become  necessary  to  ensure  this  by 
means  of  morphia.^  Of  the  influence  of  posture,  to 
allow  the  effused  blood  to  escape,  many  instances  might 
be  quoted.  Perhaps  the  most  striking  of  them  is  the 
case  of  a  wounded  soldier,  supposed  to  be  dead,  who 

^  In  the  case  of  a  soldier  in  the  American  war,  in  whom  an 
explosive  bullet  had  shattered  the  pectoral  muscle,  and  then 
entered  the  chest,  opisthotonos  occurred  a  fortnight  after  the 
injury,  and  he  was  thought  to  have  tetanus.  "  Opium  was 
administered,  and  carried  to  the  point  of  narcotization.  The 
pupil  was  contracted  to  the  size  of  a  pin-hole  during  the  whole 
treatment."     He  made  a  complete  recovery. 


WOUNDS    OF    THE    LUNG.  117 

was  carried  off  the  battlefield,  slung  anyhow  over  a 
comrade's  shoulders  •  this  rough  treatment  brought  about 
a  sudden  rush  of  blood  and  air  from  his  wounds ;  he 
revived,  and  finally  recovered.  In  other  cases,  the  later 
accumulation  of  serous  or  sero-purulent  fluid  in  the  pleura 
could  be  relieved,  day  after  day,  by  the  patient  placing 
himself  or  being  placed  in  such  a  position  that  it  could 
be  poured  out  of  him.  Further  examples  of  this  influence 
of  posture  are  given  in  the  chapter  on  empyema,  and  on 
pages  48  and  96. 

Operative  Treatment. 

Of  all  penetrating  wounds  of  the  chest,  it  may  be 
said  that  they  must  only  be  closed,  provided  the  surgeon 
be  at  hand  to  reopen  them,  if  necessary.  Mere  com- 
pression of  the  lung  by  the  blood  effused  will  tend 
to  arrest  bleeding.  Puncture  or  aspiration  may  be 
necessary.  But  if  the  bleeding  still  goes  on,  then  the 
surgeon's  last  resource  must  be  an  operation,  freely 
exposing  the  lung,  and  enabling  him  to  plug  or  suture 
the  wound  in  it,  or  apply  a  ligature  at  the  source  of 
haemorrhage.  As  regards  this  operation,  in  addition  to 
M.  Quenu's  case  (see  'Haemorrhage  into  Pleura'),  the 
three  following  cases'  (1885,  1893,  and  1894)  illustrate 
with  what  degree  of  success  this  dangerous  measure  may. 
be  carried  out. 

I.  A  man,  aged  20,  shot  himself  with  a  revolver  in 
the  left  side  of  the  chest  ;  there  was  extensive  haemorrhage 
into  the  pleura,  with  grave  collapse  of  the  patient  An 
incision,  five  inches  long,  was  made  through  the  third  inter- 
costal space  ;  a  great  quantity  of  blood  was  let  out  ;  a  wound 
was  found  in  the  lower  edge  of  the  upper  lobe  of  the  lung. 
The   lung  was   drawn    forward  ;  the   wounded  portion  was 

'  Omboni  of  Cremona,  Delorme,  and  Michaux.  For  references, 
see  discussion  on  Reclus'  paper,  Congres  Francais  de  Chirurgie, 
1895. 


ii8  SURGERY    OF    THE    CHEST. 

secured  with  a  double  catgut  ligature  passed  beneath  it,  and 
removed.  There  was  also  a  bleeding  point  in  the  lower 
lobe  ;  this  was  closed  with  catgut  sutures,  but  one  of  them 
gave  way,  and  finally  a  ligature  was  applied.  The  patient 
did  well  at  first  ;  but  the  wound  suppurated,  and  he  died. 

2.  An  officer  in  the  army  stabbed  himself  four  times  over 
the  heart  with  an  amputating  knife  ;  he  lost  a  very  great 
quantity  of  blood,  and  was  taken  some  distance  to  a  Hospital, 
where  the  wound  was  cleansed  and  closed.  The  next  two 
days  the  bleeding  went  on,  and  he  was  in  danger  of  death 
from  exhaustion.  A  free  opening  was  now  made  into  the 
pleural  cavity  ;  three  wounds  in  the  lung,  and  two  in  the 
pei-icardium,  were  found  and  closed.  The  patient  had  lost 
an  enormous  quantity  of  blood  before  the  operation,  and  died 
a  quarter  of  an  hour  after  it. 

3.  A  young  man,  aged  18,  shot  himself  with  a 
revolver  in  the  left  side  of  the  chest,  about  an  inch  outside 
the  nipple,  and  was  at  once  admitted  to  Hospital ;  he  was 
conscious  ;  the  external  haemorrhage  was  nothing  ;  there 
was  no  marked  feeling  of  oppression  ;  the  house-surgeon 
closed  the  wound  with  a  collodion  dressing.  '  Next  morning, 
going  my  rounds,  I  find  him,  twelve  hours  after  the  injury,  in 
acute  suffering,  very  pale,  with  oppression,  and  a  sharp  pain 
in  the  side,  making  all  movement  of  the  chest  impossible. 
Examination  reveals  complete  dulness  over  the  lower  two- 
thirds  of  the  left  side  of  the  chest,  with  complete  loss  of 
vocal  vibrations,  and  well-marked  oegophony  ;  it  is,  therefore, 
impossible  to  doubt  that  there  is  a  profuse  haemorrhage  into 
the  left  pleura.  Fearing  to  be  too  hasty  in  interfering,  I 
decide  to  wait  a  little  longer,  and  to  see  if  he  improves 
during  the  day ;  I  see  him  again  in  the  afternoon  ;  his 
general  condition  is  worse,  the  dull  area  seems  larger,  his 
oppression  is  intense  ;  face  pale  and  distressed,  pulse  small, 
temperature  ioo'4  ;  I  hesitate  no  longer,  and  operate  at  once." 
The  wound  was  thoroughly  cleansed  and  examined  ;  a  large 
U-shaped  flap  of  skin  and  muscles  was  turned  upward  ;  the 
seventh  and  eighth  ribs,  three  or  four  inches  of  each,  were 
resected  ;  the  intercostal  muscles  and  the  pleura  were  raised 
as  a  flap,  following  the  line  of  the  skin  and  muscle  flap  ;  the 
divided  intercostal  arteries  were  secured.  A  quantity  of 
blood  and  air  escaped  from  the  pleura  ;  the  blood,  fluid  and 
clots  together,  came  to  nearly  a  quart  ;  the  lung  and  the  peri- 
cardium were  freely  exposed  to  sight  and  touch.  There  was 
no  wound  on  the  surface  of  the  lung,  but  blood  kept  trickling 
down  from  its  inner  surface,  and,  on  turning  outward  the 


WOUNDS    OF    THE    LUNG.  119 

anterior  edge  of  the  lower  lobe,  M.  Michaux  got  a  good 
view  of  the  bleeding'  point,  on  the  inner  aspect  of  the  lung, 
below  its  root,  close  to  the  lower  border  of  the  pulmonary 
vessels.  Since  the  bleeding  was  not  very  free,  and  since  he 
feared  that  by  using  the  catch-forceps  he  might  obliterate 
some  important  vessel,  he  simply  plugged  the  bleeding  part 
with  iodoform  gauze,  bringing  the  end  of  the  gauze  outside 
the  chest  :  he  put  in  two  large  drainage  tubes,  and  sutured 
everything  in  its  place.  The  operation  took  less  than  half- 
an-hour.  A  week  after  it,  slight  suppuration  occurred.  The 
patient  made  a  perfect  recovery. 

In  relation  to  these  most  valuable  cases,  we  may  take 
the  opinions  expressed  on  M.  Quenu's  case  last  year,  at 
the  Societe  de  Chirurgie  (Nov.  6th,  1895).  ^^-  Delorme 
said  that  in  a  case  of  persistent  haemorrhage,  one  ought 
without  delay  to  open  the  chest ;  and  if  the  opening  of 
the  wound  in  the  lung  were  too  small  to  admit  a  plug  of 
gauze,  one  ought  to  enlarge  it  sufficiently  to  plug  the 
wound  from  the  bottom.  M.  Michaux  and  M.  Berger 
were  both  in  favour  of  operation  in  such  cases ;  but 
M.  Lucas-Championniere  thought  that  the  modern 
tendency  to  interfere  in  cases  of  hccmothorax  after  wound 
of  the  lung  is  carried  too  far ;  and  that  in  most  cases, 
absolute  immobilization  of  the  chest  will  stop  the  bleed- 
ing, and  the  least  disturbance  of  the  patient  may  prolong 
it  and  cause  death. 

And  certainly  the  following  cases^  seem  to  show  that 
no  haemothorax  can  be  so  severe  that  it  may  not  of  itself 
stop  just  short  of  death. 

I.  A  young  officer,  in  a  fit  of  melancholy,  shot  himself  in  the 
left  side  of  the  chest.  '  I  found  him  in  a  desperate  state, 
almost  pulseless,  half-conscious,  pale,  shivering,  his  forehead 
covered  with  sweat,  eyes  sunken,  lips  blue,  breathing  irregu- 
lar and  laboured  ;  there  was  dulness  over  the  whole  side  of 
the  chest,  and  the  heart  was  pushed  over  to  the  opposite 
side.      I    very    thoroughly    cleansed    and    disinfected    the 

'  Riedinger,  loc.  cit.  Jonnesco,  "  Congres  Fran.  deChir.,"  1895, 
p.  99. 


I20  SURGERY    OF    THE    CHEST. 

entrance-wound,  and  applied  a  well-fitting  dressing,  and  kept 
him  flat.  He  gradually  came  to  himself,  accepted  the  situa- 
tion, and  lay  perfectly  still.  With  each  fit  of  coughing,  he 
spat  up  a  considerable  quantity  of  blood.'  The  haemoptysis 
ceased  in  a  few  days  ;  the  blood  was  absorbed  ;  and  he 
made  a  complete  recovery.  The  bullet  was  removed  from 
his  back,  a  year  later. 

2.  An  officer,  in  a  duel,  received  a  sword-wound  in  the 
second  right  intercostal  space,  wounding  the  lung.  There 
was  free  external  haemorrhage  ;  he  had  two  attacks  of 
syncope,  and  suffered  intense  dyspnoea.  That  evening,  he 
had  two  slight  attacks  of  haemoptysis,  and  next  day  there 
was  an  enormous  effusion  of  blood  in  the  pleural  cavity 
and  absolute  dulness  of  the  right  side.  An  exploratory 
puncture  drew  off  pure  blood.  No  operation  was  done  ;  the 
hemoptysis  ceased  on  the  third  day,  and  the  blood  was  all 
absorbed  in  about  a  fortnight. 

Thus  the  matter  stands  ;  at  any  rate,  we  must  be  pre- 
pared, should  all  other  measures  fail,  to  attempt  to  find 
and  secure  the  wound  in  the  lung,  for  we  must  remember 
Ch.  Nelaton's  statistics^  Of  86  cases  of  penetrating 
wound  of  the  chest  with  haemorrhage  into  the  pleura, 
only  2  2  recovered  without  operation  ;  20  were  treated  by 
puncture  or  incision  of  the  chest,  to  relieve  the  pressure 
of  the  effused  blood,  and  4  of  them  died  ;  44  died  of 
the  haemorrhage,  without  operation. 

Of  the  later  or  ultimate  troubles  that  may  follow  a 
wound  of  the  lung,  some  are  described  elsewhere  ;  others 
offer  no  opportunity  for  surgery.  As  to  the  removal  of 
foreign  bodies  after  the  patient  has  recovered  from  his 
wound,  each  case  must  be  decided  on  its  own  merits. 
So  far  as  I  know,  the  Rontgen  rays  have  not  yet  been 
employed  for  this  purpose :  and  Von  Bergmann  has 
recently  warned  us  that,  even  if  a  foreign  body  can  be 
exactly  localized  by  means  of  them,  it  may  still  be  wrong 
to  interfere  with  it. 


■  Ch.  Nelaton  :  "  These  de  Paris,"  if 


CHAPTER  X. 

WOUNDS  OF  THE   HEART. 

Surgery  of  the  heart  has  probably  reached  the  limits  set 
by  Nature  to  all  surgery :  no  new  method,  and  no  new 
discovery,  can  overcome  the  natural  difficulties  that 
attend  a  wound  of  the  heart.  It  is  true  that  '  heart 
suture'  has  been  vaguely  proposed  as  a  possible  pro- 
cedure, and  has  been  done  on  animals  :  but  I  cannot 
find  that  it  has  ever  been  attempted  in  practice.  (See 
the  chapter  on  "Pericardial  Effusions.")  There  is  a  great 
quantity  of  very  careful  clinical  records  of  heart-wounds, 
and  of  foreign  bodies  in  the  heart :  especially  the  very 
valuable  monographs  by  Purple, ^  Fischer,2  Stelzner,^ 
Riedinger,  and  Rose.'* 

History. 

Fischer,  reviewing  the  whole  history  of  wounds  of  the 

heart,  begins  with  a  fact  noted  in  the  Iliad  of  Homer, 

that   a  foreign  body  in  the  heart  may  be  observed  to 

move  with  the  heart's  movements. 

'  He  fell :  the  spear-point  quivering  in  his  heart, 
Which,  with  convulsive  throbbing,  shook  the  shaft. 'S 


I  Wounds  of  the  Heart,  "  New  York  Journ.  Med.,"  1855,  p.  411. 
Analysis  of  42  cases. 

=  Die  Wunden  des  Herzens  und  des  Herzbeutels.  Langen- 
beck's  Arch.,  1868,  ix.,  pp.  571-907-     Analysis  of  452  cases. 

3  Deutsche  Ges.  f.  Chir.,  1887,  i.,  p.  58-  •  t^  t, 

■•  Hertamponade :  ein  Beitrag  zur  Herzchirurgie.  "Deutsche 
Zeitschrift  fur  Chir.,"  1884,  xx.,  p.  329-410- 

■=^Lord  Derby's  Translation,  xiii.,  498. 


122  SURGERY    OF    THE    CHEST. 

But  since  Hippocrates  taught  that  all  wounds  of  the 
heart  are  necessarily  fatal,  since  Aristotle  and  Pliny 
contended  that  the  heart  is  so  essential  to  life  that  it  never 
suffers  disease,^  and  Fallopius  declared  that  if  it  were 
wounded  it  could  never  heal,  being  too  hard,  always  in 
motion,  and  of  an  inflammatory  heat,  we  cannot  wonder 
that  little  attention  was  paid  to  such  wounds  before  the 
end  of  the  17th  century.  Those  most  in  advance  of 
their  times  in  the  earlier  centuries  were  Albucasis  (iioo), 
who  advised  that  one  should  cut  down  on  an  arrow-head 
in  the  heart;  Sanctorius  (1560),  who  made  some  ex- 
periments on  rabbits;  Hollerius  (1500),  who  taught  that 
a  wound  of  the  heart  is  not  necessarily  fatal ;  and  Wolf 
(1640),  who  gave  the  first  positive  description  of  a  healed 
wound  of  the  heart.  Forty  years  or  so  before  Wolf, 
Zacchias  published  the  first  case  of  a  needle  in  the  heart : 
the  patient  died  on  the  sixth  day,  '  because  the  noblest 
organ  in  the  body  cannot  survive  a  solution  of  its  con- 
tinuity.' In  the  1 8th  century,  the  observations  began 
to  be  more  numerous  ;  and  in  1760  Morgagni  first 
pointed  out  the  vital  fact,  that  death  is  mostly  due  to 
compression  of  the  heart  by  the  blood  effused  into  the 
pericardium.  In  1800,  Richter  spoke  against  the  use 
of  the  probe,  and  showed  how,  by  keeping  the  patient 
still,  and  applying  leeches,  one  might  hope  to  keep 
the  wound  sealed  with  a  clot.  Among  those  who 
came  after  Richter,  the  names  of  Larrey,  Dupuytren, 
Jamain,  and  Zametti  are  especially  to  be  noted.  Except 
for  Guthrie  (1848),  the  subject  has  been  more  studied  in 
other  countries  than  in  England. 

As  regards  experiments  on  animals,  many  observations 
have  been  made  from  time  to  time  :  the  more  important 

'  Solum  hoc  viscerum  vitiis  non  maceratur,  nee  supplicia  vitse 
trahit.     I.aesumque  illico  mortem  affert. 


WOUNDS    OF    THE    HEART.  123 

are  those  of  Jung  (1835),  ^^^  demonstrated  by 
acupuncture  that  the  heart  wall  is  little  sensitive  to  pain, 
and  observed  the  lowering  of  the  pulse  on  the  introduc- 
tion of  the  needle  :  those  of  Virchow,  who  demonstrated 
the  same  indifference  to  pain  on  stimulation  of  the 
cavities  of  the  heart ;  those  of  Castelnau  and  Ducrest, 
who  observed  the  passage  of  small  foreign  bodies  from 
the  saphena  vein  into  the  right  ventricle  ;  and  those  of 
Block  (1882),  and  Watson  (1887).  One  may  also  count 
among  experiments  on  animals  the  many  instances  where 
foreign  bodies,  shot  or  bullets,  have  been  found  encap- 
suled  in  their  hearts  :  a  fact  demonstrated  so  far  back 
as  1600  by  Weber. 

Such  are  the  chief  landmarks  in  the  history  of  the 
surgery  of  the  heart :  tradition  and  imagination  stood 
in  the  way  of  it  for  centuries  :  and  when  we  come  to  the 
history  of  the  operation  for  empyema,  we  shall  again 
see  the  same  conflict  between  authority  and  clinical 
facts. 

General  Course. 

That  a  gunshot  wound  of  the  heart  is,  in  nearly  every 
case,  at  once  fatal,  may  be  seen  from  the  fact  that  during 
the  whole  of  the  American  War  only  four  cases  came 
under  treatment.  Larrey  is  said  to  have  had  seven 
cases :  but  these  all  occurred  in  civil  practice,  not  in  war. 
Dupuytren  is  said  to  have  had  eleven  cases.  Death 
from  a  gunshot  wound  of  the  heart  may  be  apparently 
instantaneous,  but  as  a  rule  there  is  some  sort  of  auto- 
matic movement  at  the  moment — a  gasp  for  breath,  or  a 
word  or  two,  or  a  convulsive  action  —  but  the  popular 
notion  of  persons  springing  up  in  the  air,  when  shot 
through  the  heart,  is  not  verified  by  facts.  The  manner  of 
death  is  doubtless  due  to  the  immediate  stoppage  of  the 


124  SURGERY    OF    THE    CHEST. 

heart  by  the  rush  of  blood  into  the  pericardium,  not  to 
inhibition  of  the  vital  centres  by  shock.  Of  the  four 
cases  recorded  in  the  American  War,  which  were  not  at 
once  fatal,  one  patient  lived  just  over  an  hour  ;  one,  who 
had  also  other  wounds,  lived  about  two  days  ;  one  lived 
fourteen  days,  and  then  died  suddenly ;  one  lived  two 
and  a  half  years,  and  then  died  of  softening  and  rupture 
of  the  right  auricle. 

Of  survival  after  stab-wound  of  the  heart  there  are 
many  instances,  and  needles  have  often  been  found  pos^ 
mortem  in  the  hearts  of  patients.  As  in  wounds  of  the 
lung,  so  here,  there  is  generally  a  medico-legal  aspect 
of  the  case  :  and  the  grave  question  may  be  raised  be- 
tween suicide  and  murder.  Thus,  the  direction  of  the 
wound  must  be  considered,  as  in  a  case  recorded  by 
Casper,'  where  a  man  was  stabbed  over  the  heart  with 
a  pocket-knife.  The  defence  was,  that  he  had  run  in  on 
the  other  man's  knife ;  but  there  were  two  wounds,  they 
ran  from  above  downward,  and  converged  toward  the 
heart :  and  on  this  evidence  the  accused  was  condemned. 
In  another  case,  a  man  was  found  dead,  shot  through  the 
heart :  the  bullet,  entering  an  inch  and  a  half  from  the 
left  nipple,  and  passing  out  at  the  back  two  inches  from 
the  ninth  dorsal  vertebra,  had  torn  open  the  left  ventri- 
cle, then  passed  through  the  diaphragm,  and  wounded 
the  upper  edge  of  the  spleen.  His  left  hand  had  dried 
blood  on  its  palmar  aspect,  and  there  was  a  small  wound 
of  the  index  finger,  with  fracture  of  the  first  phalanx. 
He  had  therefore  shot  himself  with  his  left  hand,  pointing 
the  weapon  downward. 

In  a  case  of  gunshot  wound,  the  position,  in  which 
the  body  was  found  lying,  gives  us  no  sure  means  of 


'Forensic  Medicine,  "  Syd.  Sec.  Transl."  1868,  i.,  p.  192. 


WOUNDS    OF    THE    HEART  125 

distinguishing  between  murder  and  suicide.  A  more 
sure  sign  is  given  if  the  hand  be  found  firmly  grasping 
the  weapon  :  in  one  or  two  cases  it  has  been  necessary 
even  to  saw  through  the  fingers  to  remove  it.  A  mur- 
derer might  put  the  weapon  into  his  victim's  hand,  and 
close  the  fingers  over  it ;  but  it  has  been  proved  that 
rigor  mortis  cannot  imitate  this  firm  spasmodic  grasp  : 
a  rare,  but  sure  sign  of  suicide.  The  presence  of  a  second 
gunshot  wound,  in  the  head,  or  elsewhere,  in  addition  to 
a  penetrating  wound  of  the  heart,  is  not  conclusive  evi- 
dence of  murder :  there  is  more  than  one  recorded  case 
where  a  man  has  shot  himself  first  through  the  heart, 
and  then  elsewhere.^ 

It  may  be  worth  while  here  to  mention  a  case-  of 
wound  of  the  heart,  which  had  a  medico-legal  aspect  of  a 
very  different  kind.  It  happened  seventy  years  ago. 
The  patient  died,  and  the  surgeon  was  put  on  his  trial  for 
malpraxis.  '  The  treatment  throughout  was  faulty :  no 
venesection,  or  antiphlogistic  remedies ;  but  on  the  con- 
trary, in  three  days  from  receiving  the  wound,  nourishing 
diet,  bark,  etc'  The  wound  of  the  heart  was  held  to  be 
not  necessarily  fatal,  and  the  treatment  vicious  and 
faulty. 

Perhaps  this  verdict  was  not  wholly  wrong  :  it  is  impos- 
sible to  be  too  careful  to  keep  the  heart  beating  quietly  : 
not  only  at  first,  but  even  for  weeks  after  the  injury. 
Long  after  the  patient  seems  out  of  danger,  the  very 
slightest  exertion  may  cause  immediate  death. 

'  In  one  case,  the  patient  was  allowed  to  walk  about  on  the 
fifth  day  ;    and  the  day  after,  while  walking,  he  suddenly 


'  Agnew,  American  Surgical  Association,  1887,  v.  p.  243. 
^  Judicial  enquiry  upon  a  person  who  died  after  ten  days,  from 
a  wound  of  the  heart.     Neurohr,  1825 


126  SURGERY    OF    THE    CHEST. 

fainted  and  died.  In  another,  the  patient  had  been  allowed 
to  go  back  to  school ;  and  three  weeks  and  a  half  after  the 
accident,  he  fainted  and  died.  In  two  other  cases  the 
patients  died  suddenly  in  the  act  of  deftecation.' 

A  man  had  been  struck  with  a  knife  in  the  region  of  the 
heart.  On  the  fourth  day,  he  was  at  the  window  of  the  Hos- 
pital when  he  saw  his  assailant  pass  by  :  he  became  greatly 
agitated,  and  in  a  short  time  died.  Post  mortem,  the  heart 
was  found  to  have  been  wounded.^ 

A  leading  man  ^  whose  death  occasioned  much  ex- 
citement in  New  York  in  1885  ^^'^-S  shot  in  the  heart,  and 
lived  for  nearly  twelve  days.  He  suffered  no  attacks  of 
syncope  :  there  was  no  palpitation  or  irregular  action  of  the 
heart.  '  From  the  time  of  the  reception  of  the  wound  to  its 
fatal  issue,  he  was  surrounded  by  most  exciting  and  disturb- 
ing influences,  both  physical  and  moral Under  more 

favourable  circumstances,  there  seems  but  little  doubt  that 
he  might  have  recovered.'  Post  inorieni,  the  bullet  was 
found  encapsuled  in  the  septum  ventriculorum,  an  inch  and 
a  half  from  the  apex,  and  a  quarter  of  an  inch  from  the 
surface.  The  heart  was  covered  with  fibrinous  lymph  :  there 
were  30  ounces  of  sero-sanguinolent  fluid  in  the  pericardium. 

A  private  in  the  American  War  received  a  gunshot 
wound  ;  the  bullet  fractured  the  lower  jaw,  tore  the  tongue, 
and  passed  down  the  neck  into  the  chest.  The  jaw  was 
comminuted,  suppuration  occurred,  and  the  case  was  con- 
demned as  hopeless.  '  He  persisted  in  sitting  up,  and  would 
occasionally  attempt  to  make  up  his  bed  and  walk  about  the 
room  when  not  restrained.  He  died  suddenly,  fourteen 
days  after  the  injury.'  Post  mortem,  the  ball  had  penetrated 
the  right  auricle,  and  was  lying  loose  within  the  heart. 
There  were  signs  of  pleurisy  and  pericarditis,  but  these  had 
not  been  noted  during  life. 

Here  then  are  seven  instances,  in  a  group  of  cases  so 
rare  as  penetrating  wounds  of  the  heart  not  at  once  fatal, 
where  death  was  hastened  or  caused  by  want  of  absolute, 
long-continued  rest,  for  many  weeks. 

It  goes  without  saying  that  the  use  of  the  probe  in 

^  Purple,  loc.  cit. 

*"Nelaton's  Lectures  on  Surgery,"  Atlee,  1855,  p.  57. 

'""  New  York  Medical  Times,"  April,  1885. 


WOUNDS    OF    THE    HEART.  127 

these  cases  is  not  the  way  to  begin  to  save  the  patient's 

Hfe. 

A  man/  aged  24,  shot  himself  in  the  heart.  '  I  was  called 
in  haste  to  the  case  by  the  surgeon  who  had  first  seen  him, 
on  account  of  the  haemorrhage.  At  first  he  had  lost  hardly 
any  blood,  but  after  the  probe  had  been  introduced  into  the 
wound  he  had  begun  to  bleed  freely.  The  surgeon  assured 
me  that  the  probe  had  not  been  passed  deep,  and  had  not 
done  any  more  harm  than  had  been  done  by  the  bullet ; 
anyhow,  the  bright-red  blood  running  from  the  wound 
showed  some  serious  injury.'  The  patient  was  violently  ex- 
cited, and  kept  tearing  off  his  bandages.  He  was  bled  freely, 
and  watched  day  and  night  ;  but  he  persisted  in  tearing  at 
his  bandages,  even  when  he  was  fastened  hand  and  foot. 
He  died  on  the  twelfth  day,  of  pneumonia.  Fosi  viorteni., 
septum  ventriculorum  perforated,  edge  of  left  lung  wounded, 
left  pleura  full  of  blood.  '  One  gets  more  and  more  certain, 
as  one  sees  the  same  thing  happen  again  and  again,  that  the 
use  of  the  probe  in  wounds  of  the  chest  never  does  any  good, 
and  often,  as  here,  does  a  great  deal  of  harm.' 

As  to  the  general  chances  of  wounds  of  the  heart  of 
all  kinds,  Fischer's  452  cases  are  as  follows:  wounds 
of  the  heart,  401  ;  wounds  of  the  pericardium  alone,  51. 
Of  the  401  wounds  of  the  heart,  about  nine  out  of  ten 
went  through  the  whole  thickness  of  the  wall  of  the 
heart.  Of  the  51  wounds  of  the  pericardium  alone,  38 
were  uncomplicated,  13  were  complicated  with  wounds 
of  the  great  vessels.  The  different  regions  that  were 
wounded  show  the  following  percentage  :  right  ventricle, 
27-2;  left  ventricle,  22*2;  both  ventricles,  57;  right 
auricle,  6*2  ;  left  auricle,  2-8.  The  coronary  artery  may 
be  wounded  with  the  heart :  one  case  only  is  recorded 
where  the  artery  was  wounded,  but  the  heart  escaped. 

It  is  strange  that  the  internal  mammary  artery  seems 
always  to  escape  injury  in  heart  wounds.  I  can  find  no 
recorded  case  where  it  is  certain  that  they  were  both 

^  Rose,  loc.  cit.  p.  335. 


128  SURGERY    OF    THE    CHEST. 

wounded ;  .  and  should  this  happen,  the  exact  diagnosis 
would  be  impossible,  unless,  as  in  a  case  recorded  below, 
it  could  be  suspected  from  a  rapidly  occurring  hsemo- 
thorax  in  a  case  not  immediately  fatal :  nor  is  it  probable 
that  any  treatment  would  avail  to  save  the  patient. 
Wounds  of  the  left  pleura  and  of  the  border  of  the  lung 
are,  on  the  other  hand,  the  common  accompaniment  of 
wounds  of  the  heart.  In  13  out  of  Rose's  16  cases, 
the  lung  was  wounded.  From  the  wounded  lung  and 
pleura,  air  passes  into  the  wounded  pericardium  (pneumo- 
pericardium) and  from  the  pericardium  blood  may  run 
into  the  pleura.  An  exact  diagnosis  must  needs  be  diffi- 
cult or  impossible.  Most  of  the  symptoms  may  raise  a 
fear  that  the  heart  itself  is  wounded,  but  may  not  prove 
it :  and  the  mere  fact  that  the  patient  is  alive,  goes 
against  a  positive  opinion  that  it  is. 

Diagnosis. 

Diagnosis  may  be  assisted  by  the  signs  of  effusion 
of  blood,  or  of  blood  and  air,  into  the  pericardium  :  the 
action  of  the  heart  may  be  feeble  or  tumultuous,  there 
may  be  marked  pleural  or  even  pericardial  dulness,  or 
abnormal  heart-sounds.  Thus,  in  a  case  in  the  American 
War,  the  action  of  the  heart  was  weak  and  tumultuous, 
and  the  left  side  of  the  chest  exhibited  marked  dulness, 
indicating  effusion  of  blood  into  the  left  pleural  cavity. 
In  four  of  Purple's  cases,  a  bruit  was  heard,  like  blood 
passing  from  an  artery  into  a  vein  ;  in  a  fifth  case,  a 
peculiar  interrupted  metallic  tinkling  was  heard  over  the 
heart.  This  last  sound,  from  blood  and  air  together  in 
the  pericardium,  was  heard  in  one  of  Rose's  cases  ;  in 
another,  he  heard  a  systolic  whizzing  sound  at  the  apex  ; 
in  another,  a  friction  sound  ;  in  others,  the  disappearance 
of  the  area  of  cardiac  dulness,  the  tympanitic  note  on 


WOUNDS    OF    THE    HEART.  129 

percussion,  the  loss  of  the  heart-sounds,  or  a  metallic 
ring  in  them,  showed  the  presence  of  air  in  the  peri- 
cardium. But  in  any  one  case,  if  the  patient  recovers, 
the  absolute  certainty  of  the  diagnosis  may  be  called 
in  question.  The  weak  tumultuous  action  of  the  heart, 
noted  in  the  American  case,  is  also  mentioned  by  Purple, 
who  says  that  in  the  period  of  reaction  palpitations  not 
unfrequently  arise,  with  a  peculiar  trembling  of  the  organ, 
with  irregular  pulse. 

He  gives  two  cases,  where  there  seems  no  doubt  that 
the  heart  was  wounded  : — 

1.  A  young  man,  aged  19,  was  stabbed  with  a  knife 
between  the  fourth  and  fifth  left  ribs  over  the  heart.  Five 
minutes  later,  he  vomited  :  the  jaws  were  somewhat  rigid,  the 
face  covered  with  sweat,  the  eyes  sunken,  the  respiration 
irregular,  interrupted,  and  sighing  :  no  action  of  the  heart 
could  be  made  out ;  venous  blood  was  flowing  in  a  con- 
tinuous stream  from  the  wound  :  not  less  than  a  gallon  (?)  of 
blood  was  lost.  He  was  laid  on  his  back,  wet  towels  were 
put  to  his  chest,  etc.,  and  the  haemorrhage  stopped  ;  reaction 
set  in  four  hours  later,  and  he  nearly  died  ;  but  with 
morphia,  cai-eful  nursing,  and  absolute  rest  (the  catheter  was 
used  on  every  occasion  for  sixteen  days)  he  recovered. 
'  For  about  two  weeks  there  existed  a  distinct  bellows-sound 
in  the  heart.' 

2.  A  man  was  stabbed  with  a  knife  over  the  heart.  '  On 
examination  after  dilatation  of  the  wound,  the  lung  and  peri- 
cardium were  found  to  be  wounded,  and  there  existed  a 
5.uperficial  lacerationof  the  apex  of  the  heart,  half-an-inchlong. 
It  could  be  perceived  by  the  finger  how,  by  the  systolic  actipn, 
the  heart  lengthened,  and  touched  with  its  somewhat  out- 
ward-bowed apex  the  sixth  rib,  and  by  the  diastole  it 
shortened  itself.  The  movements  of  the  heart  appeared  to 
resemble  the  screw-like  movements  of  a  spiral  spring.' 
The  treatment  was  free  venesection,  rest,  low  diet,  etc.  He 
made  a  good  recovery. 

I  add  Rose's  tabular  statement  of  his  own  cases  :  his 
essay  is  of  the  greatest  value,  and  should  be  carefully 
studied. 

9 


130 


SURGERY    OF    THE    CHEST. 

ROSE'S     CASES     OF     STAB 
((f)  With   Injury  of 


No. 


Other  Injuries. 


Signs  and  Consequences  of  thk   Wound   of 
THE  Heart. 


Lacerations  of  kidney 
and  caecum. 


Severe  hsemorrhage ;  intense  pallor. 
Partial  pneumo-pericardium  (Tympani- 
tic note.  Metallic  splashing  sound, 
synchronous  with  heart ;  metallic 
ring  of  heart  wounds).     Pericarditis. 

Total  pneumo-pericardium.  (Loss  of 
dull  area  and  of  heart  sounds).  Plas- 
tic pericarditis. 


Pulse  irregular.  Heart-sounds  feeble. 
Systolic  whizzing  sound  heard  at  apex. 
Pericarditis :  later,  a  cardiac  fistula. 


(b)    Without   Injury 


Attack  of  asphyxia  through  compression 
of  heart  by  effused  blood. 


SHOT   WOUNDS   OF   THE   HEART:    IN 
(a)  "Without  Fracture 


Hasmo-pericardium. 

Friction  sound,  later  pericarditis.  After 
recovery,  there  was  left  a  murmur  in 
the  mitral  valve. 


(b)    With  Fracture 


Severe  haemorrhage  after  the  use  of  the 
probe.  Penetrating  wound  of  the 
heart,  healed  before  death  (13th  day). 
Plastic  pericarditis. 


Severe  haemorrhage.  Pneumo-pericar- 
dium (Tympanitic  note,  with  metallic 
ring  of  the  heart  sounds).  Haemo- 
pericardium. 


WOUNDS    OF    THE    HEART. 

WOUNDS  OF  THE  HEART. 
Lung — 3    Cases. 


131 


Signs  and  Consequences  of  the  Wound 
OF  THF.  Lung. 

COMI'LICATIONS. 

Result. 

Surgical  emphysema.      Parenchymatous 
haemorrhage.       Pleurisy  with  effusion. 

— 

Recovery. 

Exit  of  air  from  the  wound.        Pneumo- 

Repeated   at- 

Death. 

thorax  and  pneumo-pericardium. 

tempts  to  tear 
off  bandages. 
Tub  erculous 
cavities  in 
both  lungs. 

Haemothorax. 

Recovery. 

OF   Lung — i    Case. 


Recovery. 


ALL,  THE  LUNG  WAS  ALSO  INJURED. 
— 2  Cases. 


Haemothorax. 

Two     bullets 
in  the  lung. 

Death. 

Haemoptysis ;  surgical  emphysema 

pleu- 

Delirium  tre- 

Recovery. 

risy  with  effusion. 

mens.  Bullet 
healed    over 
in  the  lung. 

— 2   Cases. 


Haemoptysis.        Later,    consolidation    of 

Repeated    at- 

Death  13th 

the  lung. 

t  empt  s  to 
tear  off  ban- 
dages,      &c. 
Two   bullets 
in  the  lung. 

day. 

Dyspnoea  ;    surgical   emphysema  ;   pneu- 

Removal     of 

Recovery. 

mothorax  ;   pleurisy  with  effusion. 

the  bullet 
from    the 
lung. 

132  SURGERY    OF    THE    CHEST. 

Needle-Wounds  of  the  Heart. 

So  many  cases  of  this  kind  are  recorded,  and  they 
differ  in  so  many  ways  from  knife  wounds  and  gunshot 
wounds,  that  they  require  separate  consideration.  They 
have  a  distinct  character  of  their  own,  and  give  a  good 
hope  of  recovery,  and  afford  an  excellent  opportunity  for 
good  surgery,  and  for  operation.  In  some  cases,  a  needle 
or  a  knitting-needle  enters  the  heart  by  accident ;  in 
others,  it  is  inserted  for  self-destruction,  especially  by 
those  who  are  insane  ;  in  others,  it  makes  its  way  into 
the  heart  from  some  other  part  of  the  body.  Or  it  may 
be  found  posf  vwrtein  in  the  heart,  with  nothing  to  show 
how  it  got  there.  Many  of  these  cases  afford  only 
curious  reading:  others  i  have  a  practical  value  and  con- 
cern us  here. 

I.  A  girl,  a:-;ed  i8,  leaning  over  her  needlework,  ran  a 
needle  into  the  right  side  of  her  chest,  near  the  breast  ;  but 
she  was  not  sure  whether  it  remained  in  or  not.  This 
happened  on  the  2nd  of  August.  On  the  3rd  of  September, 
without  premonitory  shivering,  or  cough,  or  dyspnoea,  she  had 
an  attack  of  pleurisy  on  that  side,  which  soon  yielded  to 
treatment.  On  February  13th  of  next  year,  she  showed 
signs  of  a  slight  pneumonia  of  the  sanie  side,  with  some 
general  bronchitis  :  these  left  a  troublesome  cough.  On 
March  loth,  there  was  noted  spasmodic  action  of  the 
diaphragm.  March  26th,  obstinate  vomiting.  April  5th, 
signs  of  pericarditis  ;  weak  irregular  pulse.  Rapid  loss  of 
strength  :  death  on  April  27th,  nearly  nine  months  after  the 
accident.  Post  niortei)i^  right  lung  adherent  to  pleura,  hepa- 
tization of  the  bases  of  both  lungs.  Pericardial  adhesions  : 
more  than  a  pint  of  fluid  blood  in  the  pericardium.  The 
needle  had  passed  through  the  right  ventricle,  then  through 
the  septum  ventriculorum  :  its  point  projected  into  the  left 
ventricle,  its  eye  being  embedded  in  the  wall  of  the  right 
ventricle. 

'  Fischer,  Purple,  and  Stelzner,  loc.  cit.  ;  Callender,  "  Med. 
Chir.  See.  Trans.,"  Ivi.,  p.  203.  See  also  the  discussion  on 
Stelzner's  case,  the  last  of  those  here  quoted  :  and  Ziemssen 
"  Ueber  Nadeln  im  Herzen. "  Inaug.  Diss.  Munchen,  1884. 


WOUNDS    OF    THE    HEART.  133 

2.  A  man,  wishing  to  kill  himself,  thrust  a  darning- 
needle  into  his  heart  through  the  fifth  left  intercostal  space. 
The  mark  of  the  puncture  in  the  skin  was  just  visible.  An 
incision  was  made,  which  opened  the  pleura.  The  needle 
was  seen  to  be  fixed  in  the  heart,  and  was  withdrawn,  followed 
by  a  forcible  stream  of  blood.  The  patient  died  of  '  pleurisy  ' 
a  week  later.  Posl  mor^e;n,  the  left  ventricle  was  found 
perforated,  and  there  was  a  small  abscess  in  its  wall. 

3.  A  young  lady,  in  a  fit  of  melancholy,  drove  a  needle 
into  her  heart  through  the  sixth  intercostal  space  :  no  sign 
of  any  serious  injury  was  observed.  Next  clay,  the  eye  of 
the  needle  could  just  be  felt  under  the  skin,  and  there  was 
slight  pain  on  pressure  here.  Nothing  was  done  till  the 
fourth  day,  when  a  small  incision  was  made,  and  the  needle 
easily  removed.  It  was  two  inches  long,  and  pointed 
straight  into  the  heart  :  it  was  slightly  rusted  on  the  surface. 

4.  A  man,  aged  31,  after  a  struggle  with  another  man, 
missed  a  needle  two  inches  long  which  had  been  stuck  in  his 
coat,  and  felt  sure  it  had  entered  his  chest.  Next  day,  he 
felt  some  pain  about  the  heart,  and  came  to  Hospital  ;  but 
nothing  could  be  seen  or  felt.  He  kept  at  work  for  nine 
days,  but  his  pain  continued  and  became  worse,  and  he  com- 
plained of  palpitation  of  the  heart,  and  of  continuous  pain 
from  the  nipple  to  the  axilla,  and  down  the  inner  aspect 
of  the  arm  to  the  elbow.  In  the  fifth  space,  one  could  now 
feel  a  slight  ill-defined  fulness,  as  though  with  each  impulse 
of  the  heart  something  firmer  than  the  tissues  came  against 
the  finger  ;  the  heart-sounds  were  natural,  the  impulse  was 
not  excessive.  Incision  under  chloroform  exposed  the  eye 
of  the  needle,  moving  a  little  forward  and  to  the  right  with 
each  beat  of  the  heart  ;  it  was  withdrawn  straight  out, 
without  any  change  occurring  in  the  regular  action  of  the 
heart  ;  there  was  slight  bleeding",  which  stopped  on  pressure. 
He  was  kept  in  bed  for  four  weeks  :  he  complained  of  a 
sharp  pain  when  he  first  got  about,  but  this  did  not  last. 

5.  A  girl,  aged  11,  ran  a  knitting-needle  into  her  chest,  in 
the  region  of  the  heirt,  and  it  broke  off  short  ;  she  fainted, 
but  soon  revived,  and  was  put  to  bed  ;  the  puncture  was 
just  visible.  She  soon  became  restless,  complaining  of  severe 
pain  and  difficulty  of  breathing,  and  was  brought  to  Hos- 
pital ;  the  needle  could  be  felt  beneath  the  mark  of  puncture, 
in  the  third  space.  An  incision  was  at  once  made  here  by 
the  house  surgeon,  and  the  needle  was  seized  :  but  at  each 
attempt  to  withdraw  it,  the  heart  was  drawn  forward  with  it, 
and  the  needle  did  not  come  out.       He  sent  for  the  surgeon, 


134  SURGERY    OF    THE    CHEST. 

who  withdrew  it,  very  slowly,  a  little  way  at  a  time.  No 
severe  bleeding  followed.  It  was  noted  that  she  had  a  loud 
systolic  murmur  just  before  the  needle  was  removed.  As 
it  was  withdrawn,  the  murmur  grew  gradually  fainter,  and 
ceased  the  moment  it  was  out.  At  first,  the  needle  moved 
up  and  down  in  a  vertical  Hne  ;  as  it  was  partly  withdrawn, 
it  swung  up  and  down  like  a  pendulum.  On  removal  of 
the  needle,  the  pulse  dropped  from  120  to  90,  then  slowly 
returned  to  120,  with  respiration  50  to  60,  and  temperature 
104.     She  made  a  good  recovery. 

6.  A  man,  aged  24,  to  kill  himself,  drove  a  needle  into  his 
heart.  He  immediately  suffered  great  distress  and  oppres- 
sion ;  but  the  needle  could  not  be  felt,  nor  were  any  abnormal 
sounds  heard  in  the  heart.  Next  day  his  general  con- 
dition was  better  :  there  was  now  a  loud  systolic  murmur  at 
the  apex,  and  the  pulse  was  irregular  ;  there  was  a  red  spot 
at  the  lower  border  of  the  fifth  rib,  l|  of  an  inch  inside 
the  nipple  line  ;  a  loud  friction-sound  over  theapsx  ;  cardiac 
dulness  not  increased  ;  pulse  small,  92  ;  temp.  1007  ;  no 
abnormal  sounds  in  the  lungs  ;  respiration  shallow,  rapid, 
painful  ;  the  needle  could  not  be  felt.  Next  day,  sudden 
great  oppression,  duskiness,  small  intermittent  pulse,  shallow 
breathing,  marked  prostration  ;  loud  friction  sound  over  the 
heart,  both  in  systole  and  diastole.  Operation :  a  semi- 
circular flap  of  skin  and  muscle  was  raised,  but  still  the 
needle  could  not  be  felt  :  an  inch  of  the  fifth  rib  and  its  car- 
tilage was  therefore  resected.  '  I  now  found  myself  in  the 
pleural  cavity,  and  saw  the  lower  edge  of  the  lung;  but 
nothing  was  to  be  seen  of  the  needle.  I  packed  the  wound 
in  the  pleura  with  iodoform  gauze,  and  opened  the  pericar- 
dium in  its  long  axis,  letting  out  2  or  3  drachms  of  turbid 
fluid.  As  the  pericardium  was  still  stretched  tight  over  the 
heart,  I  made  my  incision  in  it  V-shaped,  and  could  now 
see  the  heart,  and  with  my  finger  plainly  felt  the  needle 
in  the  wall  of  the  right  ventricle,  just  beneath  its  surface. 
At  this  moment,  the  patient  struggled  for  breath,  and 
the  plug  of  gauze  suddenly  vanished  into  the  pleura, 
and  could  not  be  found  again.  1  now  attempted,  taking  the 
heart  by  its  apex  between  my  finger  and  thumb,  to  push  out 
the  needle  from  behind  forward,  having  my  finger  behind  the 
heart.  I  succeeded  in  getting  the  eye  of  the  needle  exposed, 
steadied  it  with  my  finger-nail,  and  tried  to  get  hold  of 
it  with  the  forceps  ;  but  the  heart  beat  so  hard  that  the 
needle  slipped  back  and  vanished  into  the  interior  of  the 
ventricle,  and  lay  upright  inside  it.     Nothing  more  could  be 


WOUNDS    OF    THE    HEART.  135 

done  ;  I  plugged  my  wound,  and  put  in  a  few  stitches.'  For 
the  next  few  days  the  patient  steadily  improved  :  pulse 
regular,  murmur  hardly  audible  after  the  third  day  ;  tem- 
perature once  rose  to  102°,  but  was  normal  after  the  ninth 
day.  Six  days  after  the  operation,  careful  examination  gave 
signs  of  left  pneumothorax;  the  plug  in  the  wound  was 
removed  on  the  eighth  day;  the  heart  lay  exposed  at  the 
bottom  of  the  wound,  and  was  again  examined,  but  nothing 
was  felt  of  the  needle  :  the  wound  in  the  pleura  was  healed. 
A  few  days  later,  there  were  signs  of  left  pleural  effusion, 
which  extended  to  the  middle  of  the  scapula  ;  but  this 
became  absorbed  :  he  left  the  Hospital  four  weeks  after  the 
operation,  in  perfect  health,  with  no  signs  of  trouble  either  in 
heart  or  lungs. 

These  cases,  especially  the  last  three,  show  vividly  the 
signs  of  a  needle  impacted  in  the  heart,  the  necessity  of 
operation,  and  the  risks  attending  it.  That  the  hearts  of 
animals  may  be  freely  handled  and  subjected  to 
long-continued  treatment  was  clearly  shown  by  Roy's 
celebrated  experiments,  published  in  the  Royal  Society's 
Transactions  for  1892. 

The  mark  in  the  skin  may  be  almost  invisible,  and  a 
strong  magnifying  glass  should  be  used  to  find  it.  The 
Rontgen  rays  might  give  the  exact  position  of  the  needle. 
The  skin  incision  must  be  free ;  the  needle  must  be 
drawn  out  slowly,  a  little  at  a  time.  It  is  true  that 
needles,  and  even  bullets,  may  become  encapsuled  and 
inactive  in  the  heart ; '  but  this  is  not  likely  to  happen. 

A  case  quoted  by  Riedinger  illustrates   the  need  of 

operation  in  these  cases  : — 

A  young  girl  ran  a  needle  into  her  left  breast,  near  the 
heart  :  the  injury  was  followed  by  severe  pain  and  fever. 
At  the  lower  part  of  the  breast  there  came  a  swelling,  which 
pulsated  in  time  with  the  heart.  Eighteen  days  after  the 
injury,  she  became  collapsed,  and  died.  The  swelling  was 
found  to  be  a  large  collection  of  dark-brown  purulent  fluid, 

'  For  the  whole  subject,  see  Salzer's  monograph  "  On  the  Heal- 
ing-in  of  Foreign  Bodies,"  Syd.  Soc.  Transl.,  1894,  vol.  148. 


136  SURGERY    OF    THE    CHEST. 

communicating  through  the  sixth  intercostal  space  with  the 
pericardium.  In  the  pericardium  was  more  than  a  pound  of 
similar  fluid,  and  the  needle.  The  bleeding  had  come  from 
the  pericardium,  the  heart  itself  was  not  injured. 

Among  the  curiosities  of  surgery,  we  have  to  note  a 
few  cases  where  a  foreign  body  has  in  its  wanderings 
reached  the  heart.  In  the  body  of  a  child  a  year  old, 
who  died  three  hours  after  a  convulsive  attack  with 
dyspnoea,  a  needle  was  found  lodged  in  the  right  bron- 
chus, with  its  point  in  the  cavity  of  the  right  auricle  ;  the 
pericardium  was  everywhere  adherent ;  the  needle  had 
been  missed  a  month  ago.  A  man,  after  three  days'  ill- 
ness, was  brought  to  Hospital  suffering  great  distress  and 
oppression,  and  died  in  a  few  hours.  I'osi  moriein,  the 
pericardium  was  stained  a  blackish  tint,  and  contained 
some  old  blood.  In  the  wall  of  the  right  ventricle  an 
ivory  toothpick  was  sticking.  '  Beside  the  main  track, 
there  were  three  other  punctures  in  the  ventricular 
cavity,  as  if  the  ventricle,  in  contracting,  had  come 
against  the  point  of  the  foreign  body,  which  had  thus 
dug  into  its  inner  wall  more  than  once.'  And  there  are 
three  very  strange  cases,  too  long  to  quote  here,  which 
seem  to  show,  as  Castelnau  and  Ducrest  showed  by  ex- 
periment, that  a  foreign  body  may  enter  a  vein,  and  so 
be  carried  by  the  blood-stream  into  the  right  side  of  the 
heart. 

Prognosis  in  Wounds  of  the  Heart. 

In  those  rare  cases  that  recover,  healing  takes  place  by 
the  sealing  of  the  wound  with  blood -clot,  and  by  the 
formation  of  adhesions.  A  well-formed  fibrinous  plug  was 
already  present  in  a  case  where  death  occurred  on  the 
third  day ;  in  another  case,  of  death  on  the  fifth  day, 
there  was  already  a  firm  scar ;  in  another,  that  died 
on  the  fifth  day,  there  was  a  layer  of  fairly  strong  clot  be- 


WOUNDS    OF    THE    HEART.  137 

tween  the  heart  and  the  pericardium,  about  the  size  of  a 
florin,  and  of  considerable  depth,  giving  a  rough  look 
like  goose-skin  to  the  surface  of  the  heart.  In  a  case  of 
death  sixteen  hours  after  injury,  the  wound  in  the  peri- 
cardium was  already  adherent  to  the  diaphragm. 
Healing  is  favoured  by  the  complex  arrangement  of  the 
layers  of  the  heart-wall ;  and  it  is  probable  that  the  heart 
bleeds  only  in  diastole,  not  in  systole. 

There  are  many  secondary  and  ultimate  troubles  that 
may  follow  a  wound  of  the  heart  not  of  itself  fatal. 
Suppuration  in  the  pericardium,  in  the  mediastinum,  or 
in  the  pleura  ;  secondary  haemorrhage  ;  a  fistulous  track 
outward  from  the  heart ;  hypertrophy,  dilatation,  aneu- 
rysm, or  ultimate  softening  and  rupture  of  the  heart ; 
dense  pericardial  adhesions.  In  several  cases,  cerebral 
embolism  has  taken  place.  A  man,i  aged  52,  stabbed 
himself  in  the  fifth  left  intercostal  space,  just  inside  the 
nipple  line,  and  was  at  once  admitted  to  Hospital, 
conscious,  able  to  speak,  frightfully  pale ;  the  pulse 
could  not  be  felt,  the  heart-sounds  could  hardly  be  heard  ; 
there  was  some  emphysema  over  the  left  side  of  the 
chest,  no  marked  dyspnoea,  no  haemoptysis  ;  marked  in- 
crease of  dulness  over  the  heart,  but  mostly  toward  the 
left  (haemothorax).  That  evening,  he  suddenly  lost 
consciousness ;  next  morning,  he  was  conscious,  but 
there  were  now  paralysis  of  the  right  arm,  weakness  of  the 
right  leg,  and  weakness  of  the  right  facial  and  hypoglossal 
nerves.      Two  days  later,  these  were  much  less  marked  ; 

'  For  this  case,  and  references  to  many  others,  and  for  a  long 
discussion  as  to  the  symptoms  and  physical  signs  of  a  wound  of 
the  heart,  see  Karplus,  "  Ein  Fall  von  Penetrirender  Herzwunde 
mit  Eraboliedes  Gehirns."  Wien.  Klin.  Wochenschr.,  1891,  p.  609. 
In  one  of  Rose's  cases,  an  injury  of  the  heart  was  followed, 
on  the  fifth  day,  by  gangrene  of  both  feet ;  the  patient  recovered 
after  double  amputation  above  the  knees. 


138  SURGERY    OF    THE    CHEST. 

they  slowly  disappeared  ;  the  blood  in  the  pleura  was 
partly  drawn  off,  partly  absorbed  ;  and  the  patient  made 
a  good  recovery. 

Treatment. 

Such  of  these  troubles  as  offer  any  hope  of  surgical 

treatment  are  mentioned  elsewhere  ;  at  present,  we  need 

only  consider  the  immediate  consequences  of  the  wound. 

The  need  of  absolute  and  perfect  rest  of  body  and  mind, 

and  of  low  diet,  are  of  course  understood  :  morphia  may 

in  some  cases  be  of  great  benefit.     To  these  measures, 

we  must  add  venesection,   for   some  cases,   where   the 

patient  is  restless,  excited,  and  heavily  oppressed,  and  the 

external  haemorrhage  is  not  profuse.      This  restlessness 

and   oppression    may   be   due   to  the   accumulation    of 

blood  within  the  pericardium  ;  and  the  patient  cannot 

hold   out   against   the   blood  setting  rapidly  round  the 

heart,  and  stopping  it ;  fatal  compression  of  the  heart, 

'  herztamponade.'     This  is  the  cause  of  death  in  wounds 

of  the  heart  that  are  at  once  fatal ;  but  if  the  wound  is 

small  the  blood  accumulates  slowly.     The  following  two 

examples'    of  compression    of  the   heart   illustrate   the 

mode  of  death  from  it,   and  the  need  for  interference, 

if  there  is  a  chance  of  it. 

I.  '  I  was  called  at  two  in  the  morning  (December,  1875) 
to  come  quickly  to  a  restaurant  in  the  town.  I  found  a 
young  physician,  one  of  my  own  pupils,  gasping  for  breath, 
speechless,  livid,  lying  on  a  bed  there  ;  his  pulse  could  not 
be  felt,  but  he  was  fully  conscious.  Over  the  upper  part  of 
the  heart  was  a  knife-wound,  about  an  inch  long,  which 
neither  bled  nor  gaped.  The  whole  picture  of  compression 
of  the  heart  was  presented  to  me  ;  and  in  fact,  the  area  of 
dulness  showed  that  the  pericardium  was  so  distended  as  I 

have   never  seen  it  during   life It  looked  as  though 

the  patient's  death  would  occur  in  a  few  minutes.     I  at  once 

^Rose,  loc.  n't.  p.  345. 


WOUNDS    OF    THE    HEART.  139 

bled  him  freely ;  and  as  the  blood  flowed,  the  pulse  began  to 
come  back,  and  the  sense  of  suffocation  grew  less.  The 
more  the  blood  flowed  from  his  vein,  the  stronger  grew  his 
pulse  ;  and  I  think  I  must  have  let  over  two  pounds  of 
blood.'  The  patient  was  kept  in  Hospital  for  five  weeks, 
under  very  strict  rules  of  diet  and  nursing  ;  the  haemorrhage 
was  absorbed,  and  he  made  a  complete  recovery. 

2.  A  man,  about  middle  age,  died  unexpectedly  and 
suddenly,  and  an  inquest  was  held.  At  the  posf  niorf.e7n 
examination,  the  pericardium  was  found  distended  with 
blood,  and  a  needle  was  found  in  the  wall  of  the  heart,  pro- 
jecting into  the  right  ventricle  ;  there  was  some  softening  of 
the  wall  round  it.  The  mark  of  puncture  of  the  skin  was 
just  visible  ;  the  needle  had  been  driven  into  his  chest 
by  accident,  three  days  before  death. 

It  is  this  compression  of  the  heart,  that  we  have  to 
remember  above  all  else  in  surgery  of  the  heart.  To 
diagnose  it,  we  must  take  every  aspect  of  the  case 
together :  the  general  state  of  the  patient  from  hour  to 
liour,  the  evidence  of  auscultation  and  percussion,  and  all 
else  that  we  can  possibly  learn  or  estimate.  i\nd  if  all 
these  evidences  together  point  to  a  steady  accumulation 
of  blood  on  the  heart,  and  if  neither  rest,  nor  venesec- 
tion, have  succeeded  in  stopping  it,  then  our  only  hope 
is  in  tapping  the  pericardium  or  making  a  small  incision 
into  it. 

I  have  endeavoured  in  this  chapter  to  put  as  clearly  as 
possible  the  hopes  and  fears  that  attend  the  treatment 
of  a  wound  of  the  heart.  Happily,  these  cases  are 
rare :  a  needle-wound  is  likely  to  do  well  after  operation: 
a  knife-wound  or  bullet-wound  gives  little  room  for 
hope,  but,  if  it  be  not  at  once  fatal,  the  surgeon  may  be 
able  even  here  to  avert  death.  Some  further  notes  on 
wounds  of  the  heart  are  given  in  the  chapter  on 
'  Pericardial  Effusions.' 

Note. — Capellen  has  just  published  a  case  where  he 
sutured  a  wound  of  the  heart :  see  chapter  on  Pericar- 
dial Effusions. 


140 


CHAPTER  XL 

WOUNDS    OF    THE    DIAPHRAGM.       DIAPHRAGMATIC 
HERNIA. 

The  position  and  action  of  the  diaphragm  make  it, 
from  a  surgical  point  of  view,  one  of  the  most  interesting 
structures  in  the  body.  We  have  to  deal  with  a  strong 
curved  muscle,  of  very  great  size,  attached  all  round  the 
chest,  deep  within  it,  never  at  rest,  working  between  huge 
serous  cavities,  able  either  to  stop  or  to  spread  infection, 
and  in  immediate  relation  with  vital  organs.  From  its 
constant  movement,  it  fails  to  heal  when  it  has  been 
wounded,  or  the  scar  is  weak,  and  may  break  down 
years  afterward.  From  its  relation  to  the  viscera,  a 
wound  of  it  may  be  followed  by  strange  unexpected 
results,  either  early  or  late.  Finally,  it  has  only  of  recent 
years  come  within  the  province  of  operative  surgery.  In 
the  literature  of  the  surgery  of  the  diaphragm,  every 
page  is  worth  reading,  and  I  would  especially  commend, 
for  pleasant  and  profitable  study,  the  essays  of  Lacher,i 
Frey,"  Rydygier,-^  and  Severeano.* 

Open    Wounds    of    the    Diaphragm.     Visible 
Diaphragmatic  Hernia. 

Of  wounds  of   the    diaphragm,  apart    from   diaphrag- 

'  Ueber  Zwerchfellshernien,  "  Arch.  f.  Klin.  Med."  1S80, 
xxvii.,  p.  268. 

^  Zur  Casuistik  der  Zwerchfellsverletzungen,  "Wien.  Med. 
Wochenschr,"  1893,  p.  160. 

3  Zur  Operativen  Behandlungen  der  Zwerchfellsverletzungen 
"Wien.  Klin.  Wochenschr,"  1892,  p.  713. 

^  Considerations  sur  les  Plaies  du  Diaphragme  par  la  voie 
thoracique,  Congres  Fran^ais  de  Chir.,  1893. 


WOUNDS    OF    THE    DIAPHRAGM.  141 

matic  hernia,  we  know  very  little  :  they  are  either 
accompanied  by  other  injuries,  or  are  suspected  rather 
than  proved.  It  is  worth  noting  that  haemorrhage,  after 
injury  of  the  chest,  may  possibly  come  from  the  dia- 
phragm, not  from  the  lung ;  but  I  know  of  no  case 
where  this  has  been  discovered  by  operation.  An 
incised  wound  rarely  exposes  the  diaphragm  to  sight 
or  to  treatment.  Still,  this  may  occur  without  hernia  ; 
or  the  hernia  itself  may  be  not  deep  within  the  thorax, 
but  close  under  the  wound.  The  following  cases  1  illus- 
trate this  kind  of  wound  and  this  kind  of  hernia,  and  are 
moreover  excellent  lessons  in  surgery. 

1.  A  soldier,  aged  21,  received  a  severe  sword-wound, 
more  than  nine  inches  long,  in  the  8th  right  intercostal  space, 
laying  open  the  pleura ;  at  each  inspiration,  the  lower  edge 
of  the  lung  protruded  at  the  posterior  angle  of  the  wound. 
The  diaphragm,  with  a  wound  four  inches  long  in  it,  was 
exposed  in  the  anterior  part  of  the  wound.  The  surgeon, 
not  being  able  to  get  at  the  upper  edge  of  the  wound  in  the 
diaphragm,  sutured  the  lower  edge  of  it  to  the  lower  border 
of  the  8th  rib,  and  thus  shut  off  the  pleural  cavity,  to  the 
great  relief  of  the  dyspnoea.  The  huge  external  wound  was 
packed  with  gauze  for  four  days,  and  then  sutured.  For  a 
week,  there  was  some  dulness  over  the  base  of  the  lung. 
He  made  a  complete  recovery. 

2.  An  old  soldier,  aged  50,  in  1882  received  a  sword-wound 
in  the  8th  left  intercostal  space,  between  the  axillary  and 
nipple  lines.  The  wound  was  sutured ;  forty-eight  days 
later,  he  noticed  a  small  swelling  under  the  scar  when  he 
coughed.  A  year  later  it  was  the  size  of  a  hen's  egg.  In 
1893  it  was  still  no  larger  ;  it  was  painful,  sometimes  dull, 
sometimes  resonant,  sometimes  gurgling  ;  he  had  pain  in  it, 
pains  in  the  chest,  dry  cough,  impeded  respiration  ;  dulness 
and  friction-sounds  over  the  base  of  the  lung.  Operation. 
A  large  elliptical  incision  was  made,  beginning  at  the  4th 
rib,  an  inch  from  the  sternum,  passing  down,  below  the 
swelling,  to  the  nth  rib,  then  passing  up,  in  the  axillary 
line,  to  the  level  at  which  it  started.  The  flap  of  skin  and 
muscle  was  raised,  the  7th,  8th,  and  9th  ribs  were  divided 

'  Frey,  loc.  cit.  Llobet,  "Revue  de  Chirurgie,"  March  10,  1895. 


142  SURGERY    OF    THE    CHEST. 

in  two  places  on  either  side  of  the  swelling",  and  raised  in  a 
separate  flap  of  bones,  intercostal  muscles,  and  pleura,  and  the 
intercostal  arteries  were  secured.  Three  or  four  ounces  of 
sero-fibrinous  fluid  escaped  from  the  pleura.  It  was  im- 
possible to  prevent  collapse  of  the  lung  by  drawing  ic 
forward  with  the  forceps,  as  the  pleural  cavity  was  blocked 
with  false  membranes  ;  air  rushed  into  the  cavity,  the  lung 
collapsed  to  a  iiiere  stump  packed  away  against  the  spine. 
The  swelling  was  found  to  consist  of  colon  and  omentum, 
contained  in  a  sac.  The  sac  and  the  omentum  were  cut 
away  ;  the  peritoneum  was  sutured,  then  the  diaphragm  ; 
the  deep  flap  was  replaced,  and  a  couple  of  silver  sutures 
put  through  the  9th  rib  ;  the  ring  in  the  intercostal  space 
was  closed  with  a  catgut  suture ;  the  huge  musculo-cutaneous 
flap  was  replaced,  muscles  and  skin  being  separately  sutured; 
the  air  in  the  pleura  was  sucked  out  with  an  aspirator,  and 
the  chest  was  dressed  and  lightly  bandaged.' 

Beside  the  skill  and  success  of  the  operation  in  this 
case,  we  have  to  note  the  idea  of  drawing  forward  the 
lung  ;  the  aspiration  of  the  air  that  entered  the  pleura 
during  the  operation ;  and  the  copious  effusion  of  blood- 
stained seriuii  that  followed  the  operation. 

General  Characters  of  Diaphragmatic  Hernia. 

Leaving  these  exceptional  cases,  we  come  to  the  ordi- 
nary examples  of  diaphragmatic  hernia,  internal,  deep 
within  the  thorax ;  due  either  to  a  congenital  gap  in  the 
diaphragm,  to  rupture  by  indirect  violence,  or  to  direct 
wound. 

In    Lacher's    tables    of    276    cases  of   diaphragmatic 

'  There  was  a  good  deal  of  depression  after  the  operation ; 
pulse  small,  rapid,  and  irregular  ;  temp.  95° ;  a  little  dyspnoea, 
resp.  36.  The  day  after  it,  the  lung  reached  to  the  lower  angle 
of  the  scapula,  and  in  a  few  days  it  was  fully  expanded.  A  week 
after  operation,  he  complained  of  severe  pain  about  the  8th 
intercostal  space  in  the  axillary  line,  and  fluctuation  could  be 
felt  here ;  the  lips  of  the  wound  were  therefore  separated  at  this 
point,  and  half-a-pint  of  sero-sanguinolent  fluid  was  let  out  of  the 
pleural  cavity  ;  a  double  drainage  tube  was  put  in  for  two  days. 
He  made  a  perfect  recovery. 


WOUNDS    OF    Tin-:    DIAPHRAGM.  143 

hernia  (excluding  one  or  two  doubtful  cases),  117  were  of 
congenital  origin,  and  150  were  due  to  injury.  In  both 
kinds,  the  hernia  is  usually  on  the  left  side;  in  the  117 
cases  of  congenital  origin,  98  were  left,  and  19  right;  in 
the  150  cases  due  to  injury,  127  were  left,  and  23  right. 
As  regards  this  left-sidedness  of  congenital  gaps  in  the 
diaphragm,  we  may  note  that  hare-lip  also  is  more  often 
on  the  left  side,  and  so  are  certain  new  growths,  of 
mixed  embryonic  structure,  in  the  palate  and  the  parotid 
region. 1  The  left-sidedness  of  diaphragmatic  hernia  after 
gunshot  or  knife  wounds  is  due  to  the  support  given 
to  the  right  side  of  the  diaphragm  by  the  liver,  and  to 
the  fact  that  the  wound  is  inflicted,  whether  for  suicide  or 
murder,  by  the  right  hand,  aiming  at  the  heart.  The  same 
rule  applies  to  rupture  of  the  diaphragm  by  general  con- 
tusion or  crushing  of  the  chest ;  such  injuries  are  about 
five  times  commoner  on  the  left  side  than  on  the  right ; 
there  is  less  support  from  the  liver,  and  the  natural 
openings  through  the  diaphragm  are  more  toward  the 
left  half  of  it. 

The  opening  in  the  diaphragm  is  usually  in  the  poste- 
rior part,  and  usually  through  its  tendinous  portion ; 
and  several  cases  have  been  recorded  where  the  hernia 
has  been  due  to  dilatation  of  one  of  the  natural  openings 
in  the  diaphragm.  In  size  and  shape,  it  varies  from 
a  small  slit  or  round  or  oval  hole  to  a  congenital 
loss  of  one-half,  and  in  one  case  the  whole,  of  the 
diaphragm.  In  congenital  cases,  other  deformities  are 
sometimes  present,  in  the  fingers  and  toes,  the  iris,  and 
elsewhere.  Only  in  a  few  are  the  displaced  viscera 
contained  in  a  sac:  in  28  out  of  the  276,  there  was  a 
sac;    25   of   these  were  congenital.      Adhesion  of   the 

^  I  may  refer  to  a  paper  of  mine  on  this  subject  in  "St.  Bart. 
Hosp.  Reports,"  1886. 


144  SURGERY    OF    THE    CHEST. 

viscera  to  one  another,  or  to  the  diaphragm,  have  seldom 
been  noted  ;  certainly  one  should  not,  by  fear  of  them, 
be  debarred  from  operation. 

Regarding  the  organs  displaced,  in  only  53  cases  was 
a  single  organ  involved ;  in  most,  two  or  three  were 
displaced  together.  In  151  cases,  the  stomach  was 
involved;  in  145,  the  colon;  in  83,  the  sxnall  intestine; 
in  45,  the  liver;  in  35,  the  duodenum;  in  27,  the 
pancreas;  in  20,  the  caecum  ;  in  2,  the  kidney. 

The  causes  of  diaphragmatic  hernia  after  an  injury,  in 
102  cases,  were  as  follows  :  in  35,  stab  on  the  left  side  ; 
in  2,  stab  on  the  right ;  in  26,  blow  or  contusion  on  the 
left  side;  in  9,  the  same  on  the  right;  in  13,  shot  on 
the  left  side  ;  in  i,  on  the  right.  In  10,  general  concus- 
sion or  crushing  of  the  chest ;  in  6,  simple  increase  of 
abdominal  pressure  (during  labour,  vomiting,  etc.).  In 
the  last  6  cases,  it  is  probable  there  was  some  predisposing 
cause.  As  we  should  expect  from  this  list  of  injuries, 
it  is  five  times  more  common  among  men  than  women. 

Congenital  hernia  hardly  concerns  the   surgeon  :    in 

almost  every  recorded  instance   it  has  been  found  on 

dissection  of  a  foetus  or  a  still-born  child.'     Or  the  child 

may  live  a  few  hours,  days,  or  months,  as  in  the  following 

cases 2 : — 

I.  A  male  child,  well  formed  outwardly,  born  after  an  easy 
labour.  'Immediately  after  birth,  it  gave  two  or  three  short, 
sharp  cries,  and  then,  though  it  seemed  to  make  every  effort, 
it  was  unable  to  produce  a  sound.  Respiration  became 
gradually  shorter  and  quicker,  cyanosis  deepened,  and  death 
occurred  an  hour  later.  T/ie  only  abnormality  fottjid  was  the 
positio7i  of  the  apex-beat^  in  tJie  right  axillary  li7te.  Only  a 
most  superficial  examination,  however,  was  made,  as  all  our 

'A  good  account  of  it  is  given  by  Mr.  Bland  Sutton,  "Med. 
Chir.  See.  Trans.,"  1884. 

-  "Boston  Med.  and  Surg.  Journ.,"  Jan.  31,  1895.  Lacher,  loc. 
cit.     See  also  Dr.  Newton  Pitt,  "Path.  See.  Trans.,"  1892,  p.  79. 


WOUNDS    OF    THE    DIAPHRAGM. 


145 


efiforts  were  concentrated  on  encouraging  him  to  breathe.' 
Posi  ino?'tem.,  the  greater  part  of  the  left  half  of  the  diaphragm 
was  absent  ;  the  stomach,  spleen,  and  most  of  the  small 
intestine  were  in  the  thorax  ;  the  left  lung  was  very  small, 
and  was  pressed  upward  and  forward.  Both  lungs  were 
compressed,  but  could  be  distended. 

2.  A  male  child,  one  year  old,  always  very  feeble,  subject 
to  convulsive  attacks,  always  cyanosed,  died  of  'heart 
disease.'  During  life  the  apex-beat  was  on  the  right  side, 
and  the  case  had  been  taken  as  one  of  'ectopia  cordis.' 
Post  mortem,  there  was  found  a  congenital  gap  in  the 
muscular  portion  of  the  left  half  of  the  diaphragm,  close 
to  the  spine  ;  part  of  the  colon,  and  the  left  kidney,  lay  in 
the  chest,  enclosed  in  a  peritoneal  sac  ;  the  heart  was  dis- 
placed far  over  to  the  right,  and  the  lung  badly  compressed. 

The  lung,  in  those  infants  who  are  still-born  or  die  soon 
after  birth,  may  be  a  mere  nodule  of  no  possible  use  ; 
and  this,  and  the  physiological  defect  of  those  infants  who 
have  grave  anatomical  deficiencies,  may  account  for  their 
inability  to  live.  Some  few  children  survive,  and  may 
even   reach   old  age. 

Diagnosis  and  Prognosis. 

Cases  are  recorded  where,  all  through  life,  the 
hernia  gave  no  trouble ;  but,  for  the  majority,  life 
was  made  a  burden  by  troubles  which  were  supposed 
to  be  due  to  dyspepsia:  pain,  nausea,  vomiting, 
dislike  of  food,  heartburn,  thirst,  colic,  constipation 
alternating  with  diarrhoea.  In  such  cases,  a  diagnosis  is 
almost  impossible ;  but  there  may  be  something,  in  this 
or  that  case,  to  lead  one  toward  it.  In  most  of  them, 
the  pains  and  troubles  were  worse  after  exertion ;  in 
others,  a  heavy  meal  gave  relief;  in  one  or  two,  the 
patient  was  conscious  after  food,  that  it  was  not  where  it 
ought  to  be,  or  the  surgeon  could  hear  gurgling  in  the 
chest ;  in  others,  there  was  a  fixed  pain  through  the  chest, 
and  a  painful  spot  in  the  hypochondrium.     In  one  case. 


146  SURGERY    OF    THE    CHEST. 

the  oesophagus  was  compressed,  the  patient  was  wholly 
unable  to  swallow,  and  soon  died.  If  the  hernia  be  very 
large,  there  may  possibly  be  a  hollowing  of  the  upper 
part  of  the  abdomen,  with  a  fulness  of  the  side  of  the 
chest. 

The  symptoms  that  immediately  attend  the  /irs^  onset 
of  a  diaphragmatic  hernia  are  especially  dyspnoea,  which 
is  usually  the  most  marked  of  all ;  pain,  oppression, 
cough,  praecordial  pain,  a  feeling  that  something  has 
given  way,  inability  to  lie  on  the  sound  side.  And  in  a 
few  cases,  the  shock  and  the  compression  of  the  lung 
have  caused  death  almost  at  once.  If  the  hernia  be 
strangulated,  the  whole  aspect  of  the  case  is  that  of  acute 
internal  strangulation  ;  and  these  cases  may  come  to 
operation. 

Starting  afresh  then,  from  a  purely  practical  point  of 
view,  we  have  to  note  that,  out  of  nearly  300  cases  of 
diaphragmatic  hernia  of  all  kinds,  a  right  diagnosis  was 
made  in  7  cases  only.  Three  signs,  above  all  others, 
may  help  toward  it :  hoUowness  in  the  abdomen  with 
fulness  in  the  chest ;  sounds  of  movement  of  stomach 
or  intestines  inside  the  chest ;  and  displacement  of  the 
heart.  And  doubtless  some  of  the  cases  diagnosed  as 
'ectopia  cordis'  are  cases  of  congenital  gap  in  the  left 
half  of  the  diaphragm. 

Next,  we  note  that  of  33  cases  of  knife  wound  of  the 
diaphragm,  collected  by  Frey  (1893),  no  less  than  29,  or 
88  per  cent.,  ended,  sooner  or  later,  in  death.  Of  these  29, 
5  died  from  penetrating  wound  of  the  stomach,  with 
escape  of  its  contents  ;  2  from  secondary  empyema ;  i 
from  cause  not  stated.  In  21,  death  was  from  strangu- 
lated diaphragmatic  hernia  ;  of  these,  in  only  7  did  the 
strangulation  take  place  at  once,  or  soon  after  the  injury; 
in    14,    it    occurred    months    or    years    after    apparent 


WOUNDS    OF    THE    DIAPHRAGM.  147 

complete  recovery — in  one  case,  twenty  years  afterward. 
Some  of  the  fourteen  had  received  warnings  of  danger, 
by  the  hernia  giving  them  trouble  from  time  to  time; 
others  were  seized  without  warning.  In  some,  the  fatal 
strangulation  was  brought  about  by  coughing,  straining, 
or  some  similar  effort ;  in  others,  it  occurred  suddenly, 
for  no  known  reason. 

Moreover,  of  the  eight  who  died,  not  of  strangulation  but 
of  other  effects  of  the  wound,  seven  had  diaphragmatic 
hernia  of  the  bowels  or  omentum  ;  and  of  the  four  who 
alone  completely  recovered,  three  had  diaphragmatic 
hernia  of  the  bowels  or  omentum,  and  in  one  the  wound 
was  on  the  right  side  of  the  chest. 

Treatment  by  Operation. 

Now,  if  anyone  will  take  these  figures  of  Frey's,  and 
arrange  them  for  himself,  he  will  see — even  after  he  has 
discounted  them  by  remembering  that  doubtless  in  many 
unrecorded  cases  of  knife-wound  the  diaphragm  is 
wounded,  and  no  harm  comes  of  it — that  a  wound  of  the 
diaphragm  is  a  very  serious  affair,  and  that  a  diaphrag- 
matic hernia  after  injury  puts  a  man  in  daily  danger  of 
death.  Years  after,  the  wound  having  never  healed,  or 
the  scar  having  slowly  yielded,  he  may  die  of  acute 
strangulation,  or  from  ulceration  or  gangrene  of  the 
nipped  bowel;  he  is  in  no  less  peril  than  a  man 
going  about  with  a  large  inguinal  or  femoral  hernia 
through  a  small  ring,  without  a  truss.  And  I  believe 
that  it  would  risk  few  lives,  and  save  many,  if  we  care- 
fully opened  up  and  explored  every  wound  which 
appeared  to  have  gone  through  the  left  side  of  the 
diaphragm,  and,  if  we  found  the  diaphragm  wounded, 
sutured  it  at  once.  If  the  stomach  or  the  bowels 
are  wounded,  there  is  all  the  more  need  to   interfere; 


148  SURGERY    OF    THE    CHEST. 

if  they  are    not,   we   shall  have   all  the   more  hope  of 
success. 1 


In  rupture  of  the  diaphragm  from  general  contusion  or 
crushing  of  the  chest,  it  is  not  likely  that  the  state  of  the 
patient  will  permit  any  operation,  even  if  an  exact 
diagnosis  is  possible  ;  yet  if  such  an  injury  be  followed 
by  intractable  vomiting,  with  other  signs  of  internal 
strangulation,  operation  is  necessary.  In  congenital 
defect  of  the  diaphragm,  though  Rydygier  suggests  that 
operation  may  be  possible,  I  cannot  find  that  it  has  ever 
been  performed  ;  it  is  hardly  possible  that  it  should  ever 
be  done  of  set  purpose. 

We  need  not  trouble  ourselves  with  Nussbaum's  sugges- 
tion that  one  should  introduce  the  whole  hand  into  the 
rectum,  and  attempt  through  its  wall  to  reach  and  draw 
down  the  hernia ;  or  with  Nelaton's  advice,  that  the 
patient  should  be  kept  standing,  and  nourished  only  by 
enemata ;  or  with  the  ingenuous  doctrines  of  yet  older 
surgeons,  that  solid  quicksilver,  or  great  quantities  of 
food,  should  be  administered,  in  the  hope  of  dragging  the 
stomach  and  bowels  back  into  place.  We  have  only 
to  consider  what  can  be  and  has  been  accomplished  by 
operation.  And  we  may  take  as  texts  four  cases,- two 
where  nothing  was  done,  one  of  primary  operation,  and 
one  of  secondary  operation. 

I.  A  man,  aged  44,  was  stabbed  in  the  5th  left  intercostal 
space,  between  nipple  and  axilla,  and  was  brought  at  once  to 
the  Hospital.     He  was  excited,  garrulous,  with  a  quick  full 


^  In  Frey's  33  cases,  all  knife-wounds,  the  stomach  or  the 
bowels  were  wounded  in  7  only  ;  the  weapon  seems  in  most  cases 
to  have  lost  its  force  by  the  time  it  reached  them,  so  that  it 
thrust  them  away  instead  of  cutting  them.  The  chance  of 
success  from  early  interference  is  less  in  gunshot  wounds 
than  in  knife-wounds. 

^Lacher,  Severeano,  ?oc.  fz7.  Dalton,  "  Journ.  Amer.  Med.  Ass.," 
June  6th,  1891. 


WOUNDS    OF    THE    DIAPHRAGM.  149 

pulse  ;  no  collapse  ;  no  sign  of  pneumothorax  or  hasmo- 
thorax  ;  pain  darting  through  the  left  side,  worse  on  deep 
inspiration  ;  and  coiitimioiis  copious  vomiting.  The  small 
wound  gaped,  and  had  bled  pretty  freely.  It  was  carefully 
cleansed  and  dressed.  Next  day,  he  was  restless,  oppressed, 
feeble ;  his  breathing  was  quick,  shallow,  and  noisy  ;  the 
heart-sounds  could  hardly  be  heard,  and  the  apex-beat 
could  not  be  felt.  The  iiomiting  still  continued.  That 
evening,  he  was  seized  with  severe  abdominal  pains.,  made 
worse  by  gentle  pressure  ;  there  were  signs  of  acute  peritonitis 
with  effusion  ;  he  was  still  vomiting.  Next  day,  he  collapsed 
and  died.  The  vomiting  lasted  lep  to  death.  Post  mortem., 
commencing  purulent  peritonitis ;  in  right  pleura,  half-a-pint 
of  dark  blood  ;  in  left  pleura,  half-a-pint  of  blood-stained 
purulent  fluid  ;  left  lung  somewhat  collapsed,  but  not 
wounded.  In  the  muscular  portion  of  the  left  half  of  the 
diaphragm,  a  clean-cut  wound  an  inch  long  ;  through  this, 
three  inches  of  the  colon,  and  some  omentum,  just  grazed  by 
the  knife,  had  passed  into  the  pleural  cavity. 

2.  A  man,  aged  27,  stabbed  himself  over  the  heart,  and 
recovered  of  his  wound.  Th'ee  years  later.,  after  four  or  five 
days  of  a  feverish  attack,  with  epigastric  pain  radiating 
through  the  abdominal  cavity,  he  was  admitted  to  Hospital. 
The  scar  of  his  old  wound,  an  inch-and-a-half  long,  was  in 
the  4th  space,  about  an  inch-and-a-half  below  the  nipple. 
Two  days  after  admission,  he  showed  all  the  signs  of  acute 
internal  strangtclatio7i,\v\i\\  high  fever  and  delirium,  distension, 
vomiting,  collapse,  agonizing  pains  in  the  epigastric  and 
praecordial  regions.  Percussion,  during  a  paroxysm  of  pain, 
gave  a  distinctly  tympanitic  note  over  the  left  side  of  the 
chest ;  the  heart-sounds  had  a  distinct  metallic  ring,  and 
could  be  heard  on  both  sides  of  the  chest,  and  toward  the 
left  axilla.  He  sank  and  died  early  next  morning.  Post 
mortem.,  slight  fulness  of  the  praecordial  region  ;  in  the  left 
pleura  were  a  large  portion  of  the  stomach,  measuring  4  by  6 
inches,  and  the  duodenum,  which  had  passed  through  an 
opening,  an  inch-and-a-half  in  diameter,  with  smooth  edges, 
in  the  middle  of  the  left  half  of  the  diaphragm.  The  hernia 
occupied  three-fourths  of  the  pleural  cavity,  compressing  the 
lung  and  displacing  the  heart,  and  bore  marks  of  strangulation. 

3.  A  woman,  aged  48,  was  stabbed  in  the  6th  left  inter- 
costal space  in  the  axillary  line,  and  was  at  once  admitted  to 
Hospital  :  the  wound  was  about  two  inches  long  ;  she 
had  dyspncea,  as  well  as  pain  ;  there  was  some  dulness  at 
the  level  of  the  wound,  and  free  bleeding  ;  but  the  house 


150  SURGERY    OF    THE    CHEST. 

surgeon  contented  himself  with  a  simple  dressing.'  The 
surgeon,  next  morning,  examining  the  wound  with  his 
finger,  found  a  great  quantity  of  blood  in  the  pleura,  and  the 
6th  rib  was  cut  right  through  ;  proceeding  to  turn  out  the 
blood  clot,  he  found  a  bit  of  cabbage-leaf  in  the  wound, 
which  he  thought,  at  first,  must  have  been  applied  to  the 
wound  and  got  sucked  into  the  pleura  ;  but,  on  resecting  three 
inches  of  the  6th  rib  and  opening  up  the  wound,  he  found 
all  the  contents  of  the  stomach,  and  part  of  its  greater 
curvature,  in  the  pleura.  He  resected  three  inches  of 
the  7th  rib,  found  the  lung  retracted  and  motionless,  and 
sutured  a  wound  in  it,  two-and-a-half  inches  long  ;  he 
sutured  a  wound  in  the  stomach,  three  inches  long,  with 
twenty-two  sutures,  cleansed  the  stomach,  and  replaced  it  in 
the  abdomen,  then  sutured  the  wound  in  the  diaphragm, 
two  inches  long ;  closed  his  external  wound  with  deep 
and  superficial  sutures,  and  drained  the  pleural  cavity  with 
iodoform  gauze.  Unhappily,  the  patient  did  not  rally,  and 
died  three  houis  after  the  operation. 

4.  A  man,  aged  26,  had  been  stabbed,  two-and-a-half 
years  ago,  in  the  7th  left  intercostal  space,  two  inches 
outside  the  nipple-line  ;  he  was  admitted  to  Hospital  and 
discharged  as  cured  in  a  few  days.  His  fatal  illness  began 
/iTe  days  before  re-admission  with  severe  pain  in  the 
umbilical  region,  complete  obstruction  of  the  bowels,  in 
spite  of  medicine,  and  vomiting  during  the  first  day,  but  not 
afterward.  On  admission,  he  was  in  a  state  of  intense 
suffering;  temp.  103°;  abdomen  hard  and  distended;  pain 
constant,  and  made  worse  on  pressure.  The  abdomen  was 
opened  in  the  middle  line:  there  was  acute  peritonitis,  and  it 
was  found  that  more  than  a  foot  of  the  colon,  and  the  whole 
of  the  omentum,  had  passed  into  the  left  pleura.  It  was 
impossible  to  draw  down  the  mass,  till  the  opening  in  the 
diaphragm  had  been  slightly  enlarged  by  incision  ;  it  was 
then  drawn  down  easily.  The  patient  was  much  collapsed, 
and  died  four  hours  after  the  operation. 

These  four  cases  deserve  careful  study,  and  prove 
beyond  all  doubt  the  necessity  of  immediate  operation. 
Let  us  then  note  what  difficulties  surround  it,  and  how 
they  may  best  be  overcome.     First,  it  is  possible  to  fail 

'  "  L'interne,  a  neuf  heures  du  soir,  se  contentant  de  lui  faire 
un  pansement  sans  lui  donner  d'autres  secours." 


WOUNDS    OF    THE    DIAPHRAGM.  151 

even  to  find  the  hernia  by  operation ;  this  has  happened 
in  one  or  two  cases.  Next,  the  operation  cases  divide 
themselves  into  two  sets  ;  in  one,  the  surgeon,  guided 
by  the  wound,  or  by  the  scar  of  an  old  wound,  operates 
through  the  pleura  ;  in  the  other,  having  nothing  to  guide 
him,  he  opens  the  abdomen  by  the  usual  method  for  acute 
internal  obstruction,  and  then  finds  he  has  to  deal  with 
a  case  of  strangulated  diaphragmatic  hernia. 

It  seems  clear  that  the  best  way  to  reach  a  diaphragmatic 
hernia  is  through  the  pleura,  not  through  the  abdomen.  It 
is  more  easily,  and  more  safely,  reduced  by  gentle  pressure 
from  above  than  by  dragging  it  down  from  below.  If  it 
is  gangrenous,  or  wounded,  or  has  fouled  the  pleural 
cavity,  these  disasters  may  be  remedied,  without  infecting 
the  peritoneal  cavity.  If  the  lung  or  the  pericardium 
is  also  wounded,  their  wounds  can  be  observed.  If  the 
external  wound  is  recent,  air  may  already  be  present  in 
the  pleura,  and  matters  will  not  be  made  much  worse  by 
admitting  more.  And  the  free  admission  of  air  to  the 
pleura,  though  it  may  for  a  time  cause  collapse  of  the 
lung,  has  this  great  advantage,  that  by  altering  the  pressure 
within  the  pleura  it  makes  the  hernia  easily  reducible. 
Finally,  it  is  much  easier  to  close  the  hole  in  the 
diaphragm  from  above  than  from  below. 

For  these  reasons,  the  pleural  operation  is  to  be 
preferred ;  and  the  surgeon,  guided  by  the  recent  wound, 
or  by  the  scar  of  an  old  one,  must  expose  the  diaphragm 
freely,  by  resection  of  ribs,  turning  upward  a  large  flap. 
In  two  cases,  both  successful,  recorded  by  Postempski, 
the  pleura  was  opened  through  the  7th  space  ;  in  one,  he 
reduced  the  bowel,  in  the  other  he  sutured  and  reduced 
the  stomach;  in  both,  he  closed  the  opening  in  the 
diaphragm.  Different  methods  of  resection,  and  of 
operation    by  flaps,   have   been   described   by   different 


152  SURGERY    OF    THE    CHEST. 

surgeons  ;  at  all  events  we  must  make  a  free  exposure 
of  the  diaphragm. 

It  is  not  likely,  in  any  recent  case,  that  the  surgeon 
will  find  the  hernia  itself  wounded ;  this  happened  in  seven 
only  of  the  33  cases  collected  by  Frey.  In  such  an  event, 
he  must  go  on  the  lines  given  in  case  3  just  quoted.  If  it 
be  gangrenous,  he  cannot,  in  all  probability,  either  resect 
it  from  the  pleural  wound,  or  draw  forward  and  fix  it; 
and  his  last  very  faint  hope  of  saving  the  patient's  life 
must  be  in  cleansing  the  gangrenous  mass,  reducing  it 
back  into  the  abdomen,  and  dealing  with  it  through  an 
abdominal  incision. 

In  the  other  set  of  cases,  the  surgeon  has  opened  the 
abdomen  in  the  middle  line  for  the  relief  of  internal 
strangulation,  and  has  then  found  a  diaphragmatic  hernia. 
The  records  of  these  cases  show  that  in  such  a  state  of 
things  the  hope  of  success  is  not  very  good.  In  one, 
the  surgeon,  after  enlarging  the  ring,  was  able  to  draw 
down  the  bowel:  but  it  went  on  to  gangrene,  and  the 
patient  died  nine  days  after  the  operation.  .  In  another, 
the  surgeon  could  not  get  at  the  ring  to  enlarge  it,  but 
at  last  managed  to  slip  his  finger  alongside  the  hernia, 
through  the  ring,  and  then  was  able  to  hook  down  the 
diaphragm  with  his  finger,  to  enlarge  the  ring,  and  to 
reduce  the  bowel.  In  another,  neither  the  enlarging  of 
the  ring,  nor  the  pulling  at  the  bowel,  availed  to  reduce 
the  hernia ;  the  surgeon  therefore  made  an  incision 
through  one  of  the  intercostal  spaces,  and  let  some  air 
into  the  pleura,  and  at  once  the  hernia  was  easily  reduced. 

This  opening  of  the  pleura  is  advocated  by.Rydygier 
for  other  reasons,  if  the  surgeon,  having  opened  the 
abdomen,  finds  a  diaphragmatic  hernia.  For  thus  he  can 
ascertain  the  state  of  the  strangulated  bowel,  and  not 
drag  at  a  coil  of  bowel  already  soft  with  gangrene ;  he 


WOUNDS    OF    THE    DIAPHRAGM.  153 

can  ascertain  the  state  of  the  pleura,  and  not  enlarge  a 
ring  that  opens  into  a  septic  pleural  cavity  ;  and  he  can 
more  easily,  having  reduced  the  bowel,  close  the  opening 
in  the  diaphragm. 

But  to  add  pneumothorax  to  abdominal  section,  in  a 
case  of  acute  internal  strangulation,  may  take  away  the 
patient's  last  hope  of  recovery  ;  and  this  method  is  only 
justified  in  the  very  worst  cases,  where  reduction  is 
otherwise  impossible. 

Note. — In  writing  this  chapter,  I  overlooked  the  valuable  case 
of  diaphragmatic  hernia  recorded  by  Dr.  Hale  and  Dr.  Goodhart 
in  the  "Clinical  Society's  Transactions,"  for  1893.  A  gentleman, 
49  years  old,  after  much  exposure  and  hard  work  in  India,  came 
home  to  England  on  account  of  ill-health.  He  complained 
chiefly  of  '  water-brash '  and  acid  eructations,  with  occasional 
vomiting :  no  evidence  was  found  of  organic  disease.  He  was 
constantly  bringing  up  mouthfuls  of  dark-coloured  mucus,  while 
about  every  week  or  ten  days  he  vomited  mormous  qnantities  of 
fluid  of  a  similar  character.  He  complained  of  heat  and  pain  at 
the  ensi/orm  cartilage.  His  hotvels  zcrre  obstinately  confined.  "With 
strict  dieting  (at  first,  milk  and  rusks :  later,  nothing  but  pep- 
tonized milk),  the  vomiting  stopped  for  a  whole  month;  then  it 
came  back  as  bad  as  ever,  and  the  stomach  was  v.-ashed  out  daily 
for  a  fortnight  with  decided  benefit ;  then  a  less  restricted  diet 
was  tried,  but  copious  vomiting  of  yeasty  foetid  fluid  at  once 
followed.  Emaciation  now  became  rapid  and  extreme.  Two 
days  before  death,  tympanitic  resonance  behind  up  to  the  angle  of  the 
scapula  was  noted,  and  retraction  of  the  abdomen.  He  was  thought 
to  be  dying  of  cancer  of  the  stomach.  Post  mortem,  a  dia- 
phragmatic hernia  was  found  containing  the'^greater  part  of  the 
stomach,  which  was  enormously  dilated,  the  pylorus,  the  duo- 
denum, the  greater  part  of  the  pancreas,  a  large  loop  of  the 
transverse  colon,  and  the  lesser  omentum.  There  was  a  distinct 
hernia  sac  occupying  the  posterior  mediastinum,  extending  across 
the  spine  from  the  oesophageal  opening  in  the  diaphragm  to  the 
opening  for  the  vena  cava  inferior. 


154 


Part  II.— DISEASES  OF  THE  CHEST. 


CHAPTER  XII. 

CARIES    AND    NECROSIS    OF    RIBS    AND    STERNUM. 
INFLAMMATION  OF  THE  ANTERIOR  MEDIASTINUM. 

npHE  ribs  and  sternum  very  rarely  suffer  acute 
-■-  inflammation,  either  that  form  of  acute  periostitis  or 
osteo-myeUtis  which  used  to  be  called  acute  necrosis,  or 
any  inflammation  analogous  to  the  acute  epiphysitis  of 
children;  but  they  are  liable  to  chronic  specific  inflam- 
mations— syphilitic,  typhoidal,  and  above  all,  tuberculous; 
not  during  childhood,  but  in  adult  life.  Yet,  if  we 
consider  the  number  of  the  ribs,  and  the  mass  of  bone 
they  represent,  it  is  evident  that  they  have  some  immunity 
from  all  forms  of  inflammation,  which  is  probably  due 
to  their  having  so  little  cancellous  tissue  in  proportion  to 
their  surface.  In  Billroth's  and  Menzel's  table  of  1196 
fatal  cases  of  caries,  arranged  according  to  the  frequency 
with  which  the  different  bones  were  affected,  the  ribs 
occupy  the  sixth  place.  Their  powers  of  repair  are  so 
great  that  simple  fracture  can  hardly  cause  necrosis,  and 
non-union  after  it  is  almost  unknown.  Gunshot  fractures 
are  sometimes  followed  by  necrosis  of  the  ribs  or  ster- 
num ;  and  for  this  reason,  and  for  the  greater  safety  of 
the  pleura,  intercostal  vessels,  and  lung,  a  splintered, 
comminuted  gunshot  fracture  should  be  at  once  treated 
by  removal  of  the  fragments,  and  of  any  spicule  or 
shattered  end  of  bone,  care  being  taken  to  avoid  making 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    155 

or  extending  a  wound  in  the  pleura.  Necrosis  has  been 
known  to  follow  resection  of  rib  in  the  operation  for 
empyema,  but  this  does  not  often  happen,  or  it  may 
follow  the  prolonged  use  of  a  hard  drainage-tube  after 
simple  incision  of  the  chest. 

Syphilitic  Caries. 

Syphilitic  inflammation  of  the  ribs  or  sternum  is  not 
common,  though  some  cases  have  doubtless  been 
assigned  to  tuberculous  disease  which  were  really  syphi- 
litic. It  may  occur  either  as  a  periosteal  node,  or  as  late 
tertiary  infiltration  of  the  bone  ;  it  is  rather  periosteal 
than  central ;  rather  gummatous  than  caseous ;  often  of 
considerable  extent  along  the  ribs ;  often  multiple : 
hence  it  may  be  mistaken  for  malignant  disease,  as  well 
as  for  tuberculosis,  and  has  been  at  least  in  one  instance 
treated  by  operation  as  for  sarcoma.  In  every  doubtful 
swelling  of  the  ribs  or  sternum,  a  patient  trial  must  be 
made  of  anti-syphilitic  remedies,  in  large  doses.  A  good 
example  of  syphilitic  disease  of  the  sternum  is  given  by 
SchuUer.^  The  patient,  aged  23,  strong  and  active,  had 
for  some  months  been  subject  to  nodular  swellings,  at 
first  hard,  afterward  softening,  over  his  sternum.  On 
admission  to  Hospital,  he  had  over  the  manubrium 
sterni  an  irregular  excavated  sore  with  undermined 
edges,  and  the  bone  beneath  it  was  at  one  point  bare  and 
soft ;  he  had  similar  swellings  over  other  bones.  Under 
proper  local  and  constitutional  treatment  the  ulcer 
nearly  healed ;  but  it  broke  down  again,  bare  bone  was 
felt,  and  a  number  of  sequestra  were  removed,  two  of 
which  were  of  considerable  size.  The  ulcer  now  healed, 
leaving  a  sinus.     But  the  disease  broke  out  elsewhere, 


'"Deutsche  Ztschr.  f.  Chir."  187S. 


156  SURGERY    OF    THE    CHEST. 

and  at  last  amyloid  disease  supervened,  and  he  left  the 
Hospital  as  incurable. 

Caries  after  Typhoid. 

Typhoid  fever  is,  in  some  cases,  attended  or  followed 
by  a  specific  periostitis,  and  the  ribs  are  often  selected 
for  its  attack.  This  typhoid  periostitis  has  been  described 
in  England  by  Sir  James  Paget,i  in  America  by  Dr. 
Keen  of  Philadelphia,  and  Dr.  Parsons  of  Baltimore  ;  - 
and  in  France  by  Dr.  Mercier;^  and  Mr.  Lockwood* 
has  found  the  typhoid  bacillus,  more  than  a  year  after 
the  fever,  in  an  abscess  over  the  tibia,  in  a  girl  nineteen 
years  of  age :  he  gives  references  to  Hintzer,  Orloif  and 
Werth,  who  also  have  found  it  in  similar  cases ;  other 
common  micro-organisms  of  suppuration  are  present 
with  it.  Mr.  Carless  has  given  a  full  account  of  it  in 
the  "Practitioner,"  Jan.,  1896.  He  who  wishes  to 
study  this  most  interesting  subject  will  find  other  cases 
recorded  by  Mr.  Stanley  in  his  work  on  Diseases  of  the 
Bones,  by  Sir  William  Savory  and  Sir  Dyce  Duckworth 
in  the  St.  Bartholomew's  Hospital  Reports,  and  by 
Dr.  Clarke  in  the  Journal  of  the  American  Medical 
Association,  April  1891. 

Dr.  Keen  collected  no  less  than  69  cases  of  disease 
of  bone  following  a  continued  fever  ;  of  these,  37  were 
typhoid.  In  10  cases,  the  bone  disease  occurred  in  the 
first  fortnight  of  the  fever;  in  27,  from  three  to  six 
weeks  after  the  onset;  in  10,  still  later.  The  bone 
most   often   attacked  is  the  tibia,  on   the  inner  aspect 


'Clinical  Lectures  and  Essays. 

=^  Toner  Lecture  ;  Smithsonian  Collection,  vol.  xv.  Washington, 
B78.     "  Annals  of  Surgery,"  Nov.  1S95. 

3  Revue  Mensuelle  de  Medecine  et  de  Chirurgie,  1879,  iii.,  p.  21. 
■•Traumatic  Infection,  1895,  P'4^- 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    157 

of    its    shaft.     It    is    to    be   noted  that  the   bones   that 

suffer  are  those  most  exposed  to  injury  or  pressure.     Dr. 

Meacham  notes  no  less  than  nine  cases  of  necrosis  after 

typhoid  in  one  year's  work  in  the  Holy  Cross  Hospital, 

Salt  Lake  City,  Utah  :  two  were  of  the  femur,  three  of 

the  sternum,  and  four  of  the  ribs.^ 

The  following  case  of  caries  of  a  costal  cartilage  after 

typhoid  was  under  my  care  some  years  ago;   it  shows 

clearly  the  need  of  very  thorough  methods  of  operation 

in  this  disease. 

A  man,  aged  40,  had  typhoid  fever  in  the  spring  of  1891, 
followed  by  periostitis  of  both  tibia;,  and  of  one  of  the  lower 
left  costal  cartilages.  Of  the  swellings  on  the  tibia;,  one  was 
absorbed  without  suppuration,  the  other  healed  after  sup- 
puration, without  exfoliation.  The  swelling  of  the  rib  slowly 
suppurated  and  was  incised,  but  did  not  heal.  In  December, 
1892,  there  was  a  sinus,  3^  inches  long,  running  downward 
and  outward  close  to  the  costal  cartilages.  I  cut  down,  and 
opened  it  at  its  lowest  point,  scraped  away  a  little  rough 
patch  on  the  lower  edge  of  one  of  the  cartilages,  and  drained 
the  sinus  for  a  long  time,  but  still  it  did  not  heal.  In 
November,  1893,  I  l^id-  open  the  whole  sinus,  and  found  a 
deep,  thick-walled  cavity,  leading  to  a  costal  cartilage,  cut 
right  across  by  caries  ;  I  resected  the  carious  parts  of  the 
cartilage,  and  the  tissues  round  the  sinus,  and  kept  open  the 
greater  part  of  the  cavity,  but  fresh  sinuses  formed  round 
it  ;  these  had  to  be  laid  open  a  fortnight  later,  and  at 
last  the  whole  wound  healed. 

I  have  heard  of  a  similar  case,  where,  the  first  operation 
having  failed,  at  the  second  a  small  patch  of  caries  was 
found  on  the  inner  aspect  of  the  rib :  when  this  had  been 
well  scraped  the  sinus  healed. 

Tuberculous  Caries. 

Tuberculous  disease  is  the  most  common  cause  of 
caries  of  the  ribs  or  sternum.     In  childhood,  these  bones 

'  "  A  Synopsis  of  Clinical  Surgery,"  Salt  Lake  City,  1895. 


158  SURGERY    OF    THE    CHEST. 

rarely  suffer ;  during  many  years'  work  at  a  children's 
Hospital,  I  remember  seeing  only  one  case  of  the  kind — 
a  little  girl  about  six  years  old.  with  a  small  chronic 
abscess  over  one  of  the  lower  left  ribs,  about  the  axillary 
line ;  a  few  months  later,  she  became  affected  with 
tuberculous  disease  of  the  spine.  Mr.  Watson  Cheyne  ^ 
points  out  that  the  disease  begins  more  often  in  the  peri- 
osteum than  in  the  interior  of  the  bone,  and  that  the  ribs 
most  often  affected  are  the  fourth  to  the  eighth,  toward  their 
middle  portions.  It  may  track  far  along  a  rib,  may  thin 
or  even  fracture  it,  may  invade  it  at  points  far  apart,  may 
attack  many  ribs  together;  in  one  case"  the  clavicle, 
sternum,  and  first  five  ribs  were  diseased ;  in  another, 
seventeen  abscesses  formed  over  the  chest  wall;  in  another, 
the  chest  wall  was  riddled  with  twenty  fistulae ;  in  another, 
every  rib  in  the  body,  as  well  as  the  spine,  was  affected. 
These  severe  cases  are  happily  rare,  and  are  rather 
proofs  of  the  need  of  early  operation  than  instances  of 
the  usual  course  of  caries  of  the  ribs.  Plate  III.  is  a 
good  example  of  this  multiple  tuberculous  osteo-myelitis. 
The  first  symptoms  are,  as  a  rule,  very  slight,  and  a 
surgeon  is  not  likely  to  see  the  case  until  a  small  swelling 
has  already  formed  over  the  rib ;  even  then  it  may  be 
hard  to  diagnose  it,  if  it  lies  beneath  the  breast,  and  has 
not  yet  begun  to  fluctuate.  The  surgeon  must  keep  in 
view  all  three  diseases — syphilis,  typhoid,  and  tubercle — 
as  possible  causes  of  any  swelling  over  the  ribs  or 
sternum.  When  the  swelling  has  suppurated,  it  may  be 
almost  impossible  to  make  a  diagnosis  between  tuber- 
culous caries  and  empyema.  'All  the  signs  that  are  said 
to  guide  us  in  this  matter — the  outward  shape  of  the 
chest,  the  expansion  of  some  intercostal  spaces  and  the 

'  "  Tuberculous  Disease  of  Bones  and  Joints,"  1895. 
=  For  References,  see  Riedinger  loc.  cit. 


Plate  hi, 


_  Multiple  Tuberculous  Osteo-Myelitis  of  the  Ribs  :  inner  aspect.  From 
Riedinger.  (One  of  the  abscesses  has  given  way  into  the  pleural  cavity 
exposing  a  sequestrum.) 


P'ace  />.  ijS. 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    159 

narrowing  of  others,  the  character  of  the  pus,  the 
irregular  outhne  of  the  dull  area,  the  recognition  of 
healthy  lung  tissue  below  the  level  of  the  swelling,  the 
fixed  level  of  the  pus,  and  so  forth — are  none  of  them 
sure  signs  one  way  or  the  other ;  the  pus  of  a  costal 
abscess  may  extend  just  as  deep  inward  as  the  pus  of 
an  empyema  ^' 

Taking  the  ribs,  apart  from  the  sternum,  and  putting 
aside  those  cases  where  the  caries  is  secondary  to  disease 
near  the  rib,  such  as  tuberculous  empyema,  we  have  to 
note  several  ways  in  which  tuberculous  caries  may  lead  to 
great  trouble.  The  pus  may  track  or  sink  far  and  wide 
in  the  soft  tissues,  and  may  even  appear  in  the  loin,  or  in 
the  front  wall  of  the  abdomen,  or  may  enter  the  sheath 
of  the  psoas  muscle,  and  point  below  Poupart's  ligament. 
Happily,  it  very  seldom  breaks  through  the  pleura,  or 
into  the  lung  ;  the  pleura  has  almost  unlimited  power  of 
protecting  itself  by  thickening  against  invasion  ;  in  ten 
years'  records  at  the  Pathological  Institute  at  Munich, 
only  two  cases  of  this  kind  are  mentioned.  But  apart 
from  these  complications,  the  patient  may  die  of  extensive 
and  persistent  suppuration,  of  amyloid  disease,  or  of 
tuberculous  phthisis.    Of  four  cases  recorded  by  Settegast,^ 

^  Messner,  Ueber  den  Durchbruch  kalter  tuberculoser  Abscesse 
der  Thoraxwandung  in  die  Lungen.  "  Verhandl.  d.  Deutch.  Ges. 
f.  Chir."  Berlin,  1893,  p.  128. 

'  "Langenbeck's  Archiv. "  xxiii.  p.  279.  Similar  cases  are  given 
by  Billroth  (Zurich,  1860-67) ;  in  one,  a  boy,  aged  14,  had  a 
chronic  abscess  over  the  last  two  ribs  on  the  right  side ;  this  was 
followed  by  the  formation  of  other  abscesses  and  fistulous  tracks 
running  upward.  Operation  showed  that  the  cause  of  all  the 
abscesses  was  the  sixth  rib,  which  was  bare  and  rough.  As  the 
boy  was  young,  and  in  fair  general  health,  nothing  more  was 
done ;  the  wound  was  healed  in  six  months.  In  another  case,  a 
man,  aged  29,  for  nearly  a  year  had  a  chronic  abscess  over 
the  third  rib  on  the  right  side,  near  the  nipple.  There  was 
spontaneous  fracture  of  the  sixth  rib.  As  he  was  suffering  with 
tuberculous  phthisis,  nothing  was  done. 


i6o  SURGERY    OF    THE    CHEST. 

one,  a  child  aged  14,  had  caries  of  the  elbow  joint,  the 
ankle-joint,  and  two  ribs,  and  died  of  amyloid  disease ; 
post  mortem,  the  sternum  also  was  found  diseased.  Two 
had  tuberculous  phthisis,  and  one  was  a  man  past  middle 
life,  being  62  years  old,  who  had  previously,, had  good 
health.  In  his  case,  the  disease  began  with  the  '  typical 
hard  infiltration '  beneath  the  right  breast :  it  broke 
down,  and  was  incised  and  drained  ;  erysipelas  followed, 
and  he  recovered  very  slowly,  and  left  the  Hospital  with 
fistulse  still  unhealed.  These  four  cases  are  dated 
1873-76,  and  we  get  better  results  now  ;  but  they  serve 
to  show  the  dangers  and  uncertainty  of  the  disease. 
Another  danger,  happily  very  rare,  is  haemorrhage  into 
the  pleura  from  erosion  of  an  intercostal  artery.^ 

In  the  following  cases,  the  abscess  involved  the  pleura 
or  the  lung : 

1.  A  woman,  aged  25,  complained  in  February  of  frequent 
catching  pain  in  the  right  side  of  the  chest,  and  in  July  was 
found  to  have  a  chronic  abscess  below  the  right  scapula.  In 
August  this  was  incised,  and  in  September  there  was  found 
extensive  caries  of  one  of  the  ribs  ;  one-and-a-half  inches  of 
it  were  resected  ;  beneath  it,  tliere  was  a  mass  of  caseous 
debris,  the  size  of  a  pigeon's  ^^'g:  this  was  cut  or  scraped 
away,  and  the  wound  healed,  but  a  fistula  remained.  In 
February  of  next  year,  she  had  an  attack  of  pleurisy  with 
effusion,  and  about  two  quarts  of  serous  fluid  were  let  out. 
She  left  the  Hospital  with  a  small  fistula. 

2.  A  man,  aged  41,  who  had  for  two  years  suffered  from 
'  inflammation  of  the  bowels,'  had  for  the  last  three  months 
been  subject  to  pains  in  the  left  side  of  the  chest,  which 
were  followed  by  an  abscess  over  the  posterior  lower  part  of 
the  chest-wall.  On  admission  to  Hospital,  he  was  much 
wasted,  the  left  side  of  the  chest  was  somewhat  flattened, 
and  there  was  effusion  in  the  left  pleura,  with  cedema  of  the 
lower  limbs,  and  slight  distension  of  the  abdomen.    On  March 


'  For  this,  and  for  the  next  three  cases,  see  Frantzel,  Ziemssen's 
Handbuchiv.  2. 448;  Hofmckl,  "Klinische  Zeit-und  Streit-Fragen," 
Wien.,  iii.  173,  and  Messner,  loc.  at. 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    i6i 

1st,  the  abscess  was  opened,  irrigated,  and  drained  ;  the 
pus  was  very  offensive  and  very  abundant.  In  April,  the 
abdomen  had  become  distended  with  fluid,  and  on  April  i6th 
he  died.  The  pos^  vioj-tem  examination  showed  tuberculous 
peritonitis  with  ulceration  of  the  small  intestines.  The 
lower  border  of  the  nth  rib,  and  the  upper  border  of  the 
I2th,  were  carious,  and  lay  in  a  purulent  cavity  which 
communicated  with  the  pleura  by  two  separate  openings. 
The  pleura  was  adherent,  and  much  thickened,  and  contained 
an  abscess  similar  to  the  one  round  the  ribs,  communicating 
with  it. 

3.  A  woman,  aged  42,  was  admitted  to  Hospital  for  a 
chronic  abscess  over  the  lower  ribs  on  the  right  side,  in  the 
line  of  the  scapula.  Her  general  health  was  much  impaired, 
and  as  bronchial  breathing  and  crepitant  rales  were  heard 
over  the  abscess,  it  seemed  probable  that  it  was  not  a  case 
of  simple  tuberculous  caries  of  the  ribs,  but  that  the  pleura 
or  the  lung  was  already  involved.  Operation  showed  exten- 
sive caries  of  the  8th  and  9th  ribs,  on  their  inner  aspect  ;  they 
were  freely  resected,  pus  was  let  out,  and  fungous  granu- 
lations were  cut  away  ;  there  was  then  seen  a  narrow  tract  of 
granulation  tissue  running  deep  into  the  lung,  just  opposite 
where  the  8th  rib  had  been  most  diseased.  The  pleura  here 
was  much  thickened,  and  the  lung  could  not  be  seen 
through  it  ;  but  except  at  this  spot  the  pleura  was  healthy, 
and  now  that  the  granulations  had  been  removed,  the  lung- 
could  be  seen  through  it,  moving  up  and  down.  The 
surgeon  scraped  the  granulations  froin  the  narrow  tract 
very  carefully,  and  found  a  sinus,  four  inches  long,  running- 
straight  into  the  lung ;  he  scraped  its  walls,  and  removed 
from  its  depths  a  small  fragment  of  indurated  lung  tissue  ; 
about  half-an-ounce  of  thin,  curdy  pus  then  flowed  from  the 
interior  of  the  lung.  A  narrow  drainage  tube  was  passed 
down  the  sinus,  and  was  kept  in  place  for  four  weeks,  as  the 
discharge  was  somewhat  copious.  Ten  days  after  the 
operation  she  coughed  up  some  pus,  and  there  were  other 
signs  that  a  bronchus  had  opened  into  the  small  cavity  in  the 
lung.  The  fistula  healed  in  five  weeks.  After  this,  she 
had  some  caries  of  the  manubrium  sterni.  She  finally  made 
a  complete  recovery.  The  tuberculous  nature  of  the  disease 
of  the  ribs  was  proved  by  the  presence  of  tubercle-bacilli 
in  the  pus. 

It  is  evident  that  any  chronic  abscess  of  the  ribs 
must   receive    immediate   and  thorough  treatment,  and 

1 1 


i62  SURGERY    OF    THE    CHEST. 

that  very  careful  search  must  be  made  for  a  patch  of 
caries.  The  diseased  rib  may  be  some  way  off,  or  only 
one  edge  of  it,  or  one  side  of  it,  may  be  carious.  It 
is  for  these  abscesses  that  Mr.  Cheyne's  method  is 
to  be  followed.  '  The  skin  and  muscles  are  reflected 
from  over  the  abscess  wall,  a  T  shaped  incision  being 
generally  necessary ;  and,  without  opening  it.,  the  abscess 
is  thoroughly  isolated  up  to  its  point  of  attachment 
to  the  rib.  It  is  then  cut  away,  a  strong  stream  of 
weak  sublimate  lotion  playing  over  the  part  at  the  time, 
so  as  to  wash  away  all  the  pus  from  the  wound.  The 
extent  of  the  affected  bone  is  then  defined,  the  rib 
divided  beyond  it  on  each  side,  and  the  whole  diseased 
part  removed.  There  then  remains  a  mass  of  tuber- 
cular tissue,  corresponding  with  the  deeper  surface 
of  the  rib,  which  must  be  very  thoroughly  scraped 
away  -,  the  wound,  having  been  well  washed  out,  is  now 
closed.'  I  have  followed  this  method  in  two  or  three 
cases  of  chronic  abscess,  and  have  found  great  advantage 
from  it. 

One  must  not  expect  in  all  cases  to  find  disease  of  the 
ribs  ;  either  the  abscess  began  just  external  to  the  ribs, 
or  the  diseased  spot  has  healed  :  but  one  is  bound  to 
search  carefully  for  it,  and  to  treat  it  then  and  there  by 
thorough  scraping  or  by  resection  of  the  rib  on  either 
side  of  the  disease.  Only  by  early  and  thorough 
methods  of  operation  can  we  hope  to  obtain  good  results. 

Caries  of  the  Sternum.     Mediastinal  Abscess. 

In  the  sternum,  as  in  the  ribs,  caries  due  to  syphilis  or 
typhoid  is  very  rare  as  compared  with  tuberculous  caries  ; 
still,  one  or  two  instances  have  been  recorded,  and  in 
any  case  the  surgeon  must  keep  all  three  diseases 
in  mind.     A  case  has  also  been  published  by  Mr,  Shield 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    163 

of  acute  osteo-myelitis  of  this  bone,  ending  in  pyiemic 
abscesses  in  the  lungs.  As  regards  tuberculous  caries  of 
the  sternum,  the  shape  and  structure  of  the  bone,  and 
the  investment  of  its  posterior  surface  by  the  tough 
resisting  membrana  sterni  posterior,  make  it  easy  to 
understand  that  the  disease  may  spread  widely  through  the 
bone,  before  the  pus  finds  its  way  outward  through 
one  of  the  intercostal  spaces.  The  disease  is  likely 
to  be  far  advanced  before  it  comes  under  the  care 
of  the  surgeon  ;  if  it  involve  only  the  anterior  aspect 
of  the  bone,  there  may  be  a  hard  infiltrating  tender 
swelling  even  at  an  early  stage ;  but  where  the  disease 
begins  at  the  back  of  the  bone,  it  can  hardly  be 
diagnosed  at  the  time  when  diagnosis  is  most  needed. 
Thus,  the  clinical  records  of  caries  of  the  sternum  are 
mostly  concerned  with  its  later  stages,  and  that  most 
dangerous  result  of  it,  abscess  in  the  loose  cellular 
tissue  of  the  anterior  mediastinum.  But  there  are  other 
forms  of  inflammation  of  this  region  beside  its  invasion 
in  caries  of  the  ribs  or  sternum.  It  may  be  infected  by 
an  operation  wound  in  the  neck  or  axilla,  or  by  direct 
injury.  There  is,  moreover,  a  chronic  form  of  inflam- 
mation, with  formation  of  dense  cicatricial  tissue,  often 
combined  with  adherent  pericardium,  the  '  fibrinous 
mediastinitis '  of  Riedinger,  or  '  indurative  mediastino- 
pericarditis.' '  We  are  here  concerned  only  with  such 
inflammations  of  the  mediastinum  as  may  come  within 
the  field  of  surgery,  including  such  as  follow  fracture 
or  gunshot  wound  of  or  near  the  sternum,  or  may  even 
come  from  severe  contusion  without  fracture. 

I.     A  young  man   was  thrown   heavily   at   football,  and 
badly  bruised.       Some  days  later,  he  began  to  be  feverish, 

'See   Dr.    Thomas     Harris'    recent     work    on    "Indurative 
Mediastino- Peri  carditis,"  London,  1895. 


i64  SURGERY    OF    THE    CHEST. 

restless,  out  of  sorts,  unable  to  sleep,  and  at  last  had  to  take 
to  his  bed.  He  complained  of  vague  general  pain  in  the 
chest, tenderness  at  the  epigastrium,  and  pain  after  swallowing 
food,  just  as  it  reached  his  stomach  ;  there  was  a  pericardial 
friction  sound,  and  crepitant  rales  over  both  bases.  He  was 
feverish  at  nights,  pulse  small  and  rapid.  Some  few  days 
later  his  fever  increased,  and  rigors  occurred,  and  a  few  days 
after  this,  slight  swelling,  tension,  and  extreme  tenderness 
were  noted  at  the  left  border  of  the  ensiform  cartilage.  At 
this  point  an  aspirating  trochar  was  put  in,  and  slowly 
pushed  onward  so  far  that  it  received  an  impulse  from  the 
heart ;  a  very  large  quantity  of  pus  was  drawn  off.  It  was 
necessary,  some  days  later,  to  repeat  the  operation  ;  then 
the  track  of  the  needle  was  laid  open,  and  the  cavity  was 
drained ;  it  did  not  wholly  close  for  six  months  ;  he  finally 
made  a  complete  recovery.' 

2.  A  man  aged  34,  received  a  gunshot  wound  just  above 
the  middle  of  the  sternum  ;  the  injury  was  followed  by  great 
pain,  irregular  action  of  the  heart,  and  inability  to  lie  down, 
but  there  was  no  proof  that  the  bullet  had  perforated 
the  sternum.  Next  clay,  there  were  swelling"  and  pain  about 
the  wound,  and  his  sputa  were  tinged  with  blood ;  suppuration 
followed,  and  became  permanent,  so  that  any  over-exertion 
or  exposure,  even  a  year  after  the  injury,  would  cause  intense 
pain,  swelling,  dyspnoea,  and  a  free  discharge  of  pus,  and  he 
would  be  laid  up  for  ten  days  or  a  fortnight.  Finally, 
a  sinus  was  left,  and  six  years  after  the  injury,  with  a  sort  of 
Nilaton's  probe  made  of  a  fine  thread  of  white  clay  lodged 
in  a  fine  silver  tube,  the  bullet  was  found  lying  two  inches 
deep,  behind  a  minute  orifice  in  the  sternum.  With  a 
trephine,  two  discs  and  a  part  of  a  third  were  removed  from 
the  sternum.  The  bullet  was  found  encysted  in  a  tough  mass 
of  dense  fibrous  tissue  ;  the  heart-beat  was  seen  clearly 
beneath  the  thickened  pericardium.  The  operation  was 
followed  by  suppuration,  absorption  of  pus,  slight  haemo- 
ptysis, and  slight  pericarditis ;  and  the  wound  did  not  heal  for 
three  months.     He  finally  made  a  good  recovery."" 

The  strong  fibrous  membrane  investing  the  posterior 

surface  of  the  sternum  may  serve  to  protect  the  loose 

areolar   tissue   of    the   mediastinum,    even    in   gunshot 

fracture   of  the   bone;    out   of  51   cases   of   this   injury 

'  Wheelhouse,  "Brit.  Med.  Journ.,"  1887,  ii.  1141. 
*  Marks,  "Trans.  Amer.  Surg.  Ass.,"  1881-83,  i.  p.  308. 


Plate  iv. 


.y  ?* 


/  '         ^  '  ■'/% 


Caries  and   Necrosis   of   the   Sternum,  with   perforation   and  formation  of 
sequestra.     (From  a  specimen  in  the  Royal  College  of  Surgeons'  Museum.) 


\Face 


CARIES  AND  NECROSIS  OF  RIBS  AND  STERNUM.    165 

in  the  American  War,  only  18  ended  in  death,  and 
Heyfelder  has  collected  notes  of  seventeen  operations  on 
the  sternum  with  only  one  death.  Wonderful  recoveries 
have  been  recorded;  one  man  hadhis  sternum  comminuted 
by  a  three-ounce  grapeshot,  tearing  open  his  left  pleura  : 
the  ball  lodged  in  the  wound,  and  was  removed  by  the 
patient  himself;  the  arch  of  the  aorta  was  exposed,  the 
lung  was  collapsed,  but  he  recovered,  and  regained 
in  great  part  his  former  health. 

As  regards  tuberculous  caries  of  the  sternum,  the  speci- 
men, I'/a/e  IV.,  is  a  good  example  of  advanced  disease  ; 
it  shows  more  than  one  perforation  through  the  whole 
thickness  of  the  bone,  the  formation  of  a  sequestrum, 
the  invasion  of  the  articulated  cartilages,  the  infiltration 
of  the  whole  bone.  On  a  bone  so  fragile  as  this  it 
would  be  dangerous  to  press  hard  with  a  trephine  ;  in 
more  than  one  case,  the  trephine  has  broken  the  bone. 
'The  treatment  must  be  conducted  on  the  ordinary 
lines,  abscesses  being  opened  and  washed  out,  bone 
being  chiselled  and  gouged  away,  and  so  forth.  In  some 
cases,  especially  of  posterior  disease,  it  may  be  necessary 
to  remove  a  portion  of  the  sternum,  generally  the 
manubrium.'  1 

The  surgeon  is  not  likely  to  see  the  case  till  there  is 
already  an  abscess.  Nor  will  he  always  find  bare  bone, 
even  in  chronic  abscess  over  the  sternum.  In  such  a 
case,  a  few  weeks  ago,  I  removed  a  large  abscess  over  the 
left  upper  costal  cartilages  and  left  half  of  the  sternum, 
following  Mr.  Cheyne's  method,  but  not  even  the  most 
careful  examination  enabled  me  to  find  any  disease 
of  bone  or  cartilage. 

There   remain    for   our    consideration   those    difficult 

'  Watson  Cheyne,  loc.  cit. 


i66  SURGERY    OF    THE    CHEST. 

cases,  where  there  is  clear  proof  of  injury  or  disease  of 

the  bone — perhaps  a  sinus,  or  an  open  wound,  or  a  patch 

of  caries — but  it  is  the  mediastinal  inflammation,  the  pain, 

dyspnoea,   feverishness,  and  oppression,  that   'dominate 

the  pathologic  scene,'  and  there  is  no  perforation  through 

the  bone.     It  is  in  such  cases  that  the  use  of  the  trephine 

is  necessary.     The  well-known  paper  on  this  subject  by 

Mr.   Ballance^  gives  full  references  to  many   cases   of 

this  kind,  and  his  operation  should  be  carefully  studied. 

He  laid  open  the  fistulous  tracks,  exposed  the  surface  of 

the  sternum,  and  found  it  looking  healthy,  trephined  it 

in   two   places,    and    cut   away   the    intervening   bridge 

of  bone  ;   let  out  the  pus  from  the   mediastinum,  and 

carefully,  with  a  Volckmann's  spoon  bent  to  a  convenient 

shape,   scraped  the  carious   disease  over   the   posterior 

aspect  of  the  sternum,  and  lightly  packed  the  wound. 

The  patient's  temperature  after  operation  was  never  above 

normal,  and  she  made  an  uninterrupted  recovery. 

At  a  meeting  of  the  Societe  de  Chirurgie,  June  17th, 

1895,  '^-  Le  Fort  reported  a  case  where  he  had  removed 

the  lower  two-thirds  of  the  sternum  for  advanced  caries 

with  multiple  fistulte.    The  operation  presented  no  special 

difficulty  :  the  bone  was  separated  from  the  mediastinum 

by  a  very  thick  layer  of  fibrous  tissue.     M.  Nicaise  said 

that  he  had  in  three  cases  performed  resection  of  part  of 

the  sternum  for  caries.     In  one  of  them  he  removed  the 

upper  end  of  the  sternum,  the  sternal  end  of  the  left 

clavicle,  and  part  of  the  two  first  costal  cartilages  :  the 

parts  beneath  them  were  protected,  as  in  M.  Le  Fort's 

case,  by  a  thick  layer  of  fibrous  tissue.     In  another,  he 

gouged  the  bone  in  many  places,  the  disease  being  widely 

diffused  through  it. 

'  "A  case  in  which  the  gladiolus  was  trephined  for  pus  pent  up 
in  the  anterior  mediastinum."  C.  A.  Ballance,  "Med  Soc.  Trans.," 
1889,  xii.  p.  8. 


1 67 


CHAPTER   XIII. 

TUMOURS  OF  THE  RIBS  AND  STERNUM. 

Secondary  malignant  disease  of  the  bones  of  the  chest- 
walls  is  so  rare,  and  so  far  beyond  the  help  of  surgery — 
save  for  one  or  two  isolated  cases — that  we  need  hardly 
consider  it.  The  ribs  and  sternum  may  suffer  in  the 
swift  universal  invasion  of  melanotic  cancer,  or  may  be 
attacked  in  the  spread  of  that  strange  form  of  cancer  of 
the  thyroid  gland  which  has  such  a  strong  predilection 
for  the  bones — but,  on  the  whole,  the  ribs  and  sternum 
are  not  often  the  seat  of  secondary  malignant  disease. 
The  total  amount  of  bone  in  them  is  enormous,  but  they 
are  not  favourable  soil  for  secondary  growths ;  even  in 
cancer  of  the  breast, ^  so  near  them,  they  often  escape — 
it  is  rather  the  spine,  or  the  upper  part  of  the  humerus, 
or  of  the  femur,  that  is  attacked. 

And  some  forms  of  primary  growth  are  so  rare  that 
they  need  only  be  mentioned.  Lipoma,  fibroma,  simple 
osteoma  :  these  have  been  recorded,  and  it  is  to  be  noted 
that  a  fibroma  of  the  ribs  may  have  processes  closely 
adherent  to  the  pleura.  Madelung  had  a  case  of  hydatid 
cyst  of  the  sternum;  but  it  remains  one  of  the  curiosities 
of  pathology  :  out  of  33  cases  of  hydatid  of  the  bones, 
collected  by  Reczsy,  not  one  was  in  the  ribs  or  sternum. 
A  naevoid  growth  over  the  ribs  is  common  enough  :  in 

'  It  is  worth  noting  that  primary  cancer  of  an  outlying  lobule 
of  the  mammary  gland  may  sometimes  present  itself  as  a  small 
hard  nodule,  fixed  firmly  down  on  one  of  the  ribs,  at  the  very 
margin  of  the  breast.  I  have  had  such  a  case,  which  had  been 
diagnosed  as  '  periostitis  of  a  costal  cartilage.' 


i6S  SURGERY    OF    THE    CHEST. 

one  case,  it  was  mistaken,  before  the  operation,  for  a 
lipoma ;  and  during  it,  for  hernia  of  the  lung. 

The  great  group  of  new  growths  with  which  alone  we 
are  now  concerned  is  that  of  the  enchondromata  and 
sarcomata — tumours  so  mixed  in  structure  that  they  are 
like  the  new  growths  of  the  parotid  region.  On  the 
whole,  those  of  the  sternum  approach  the  type  of  pure 
sarcoma — those  of  the  ribs  are  more  cartilaginous. 
Sarcoma  of  the  sternum  tends  to  be  central  rather  than 
sub-periosteal ;  enchondroma  of  the  ribs  tends  to  occur 
toward  their  cartilaginous  ends,  and  has  often  been 
rioted  after  an  injury.  Sarcoma  of  the  sternum  has 
been  mistaken  for  aneurysm,  and  aneurysm  for  it.  And 
all  these  growths,  as  they  increase,  thin  and  destroy  the 
pleura  beneath  them,  and  are  likely  to  invade  the  medias- 
tinum and  the  lung,  or  to  form  secondary  deposits  in 
them.  From  the  point  of  view  of  operative  surgery,  it  is 
impossible  for  the  surgeon  to  tell  beforehand  what  he 
will  find ;  he  may  succeed  in  removing  a  very  large 
growth  without  even  wounding  the  pleura,  or  he  may 
attack  a  small  swelling  over  the  ribs,  and  find  a  mass  of 
growth  behind  them,  and  a  large  gap  in  the  pleura ;  or 
he  may  believe  he  has  to  deal  only  with  the  chest-wall, 
and  then  come  suddenly  face  to  face  with  the  dilemma, 
either  to  abandon  the  operation,  or  to  remove  a  part 
of  the  lung  or  of  the  diaphragm. 

I.'  '  In  1861,  a  patient  consulted  me  about  a  small,  very 
painful,  swelling-  at  the  level  of  the  fourth  intercostal  space. 
It  had  been  punctured,  in  the  belief  that  it  was  fluid,  but 
nothing  had  come  from  it.  I  made  an  exploratory  incision, 
and  to  our  astonishment  we  found  that  we  had  to  deal  with  a 
solid  tumour  of  the  lung,  adherent  to  the  pleura,  and  not 
connected  with  the  ribs.  I  drew  it  forward,  shut  off  the 
pleural   cavity   with  numerous  points  of  suture  all  round  it, 

'  Pean,  "  Congres  Fran9ais  de  Chirurgie,"  Paris,  1895,  p.  77. 


TUMOURS   OF   THE   RIBS   AND   STERNUM.       1G9 

and  removed  it  with  the  f,falvano-cautery  ;  and,  as  the  bleed- 
ing was  troublesome,  left  some  pairs  of  forceps  on  the 
bleeding  points.  She  recovered,  and  was  in  good  health  the 
year  after  the  operation.' 

2.'  A  man,  aged  24,  in  good  general  health,  had  a  hard, 
rounded,  flattened,  shelving  growth  over  the  right  ribs,  from 
the  fourth  to  the  seventh,  firmly  united  to  them,  and  extend- 
ing from  near  the  sternum  to  near  the  anterior  axillary  line. 
He  had  noted  it  four  years.  The  veins  over  it  were  dilated,  the 
skin  was  not  adherent,  the  axillary  olands  were  not  enlarged. 
There  was  no  dulness  of  the  mediastinum,  no  displacement 
of  the  heart  ;  faint  vesicular  breathing  was  heard  in  the 
region  of  the  growth,  no  rales,  no  friction-sounds.  Operation: 
Nov.  8th,  1888  :  a  large  flap  was  raised,  and  it  could  then 
be  made  out  that  the  intra-thoracic  portion  of  the  growth  was 
much  larger  than  the  external  swelling.  Four  inches  of  the 
fourth  rib  were  removed,  and  then  the  fifth  rib  was  similarly 
treated  ;  at  this  moment,  the  pleura,  which  was  very  thin, 
was  torn,  and  air  was  heard  entering  the  chest.  Part  of  the 
sixth  rib  was  now  resected,  pleura  and  all,  and  the  tumour 
was  raised,  exposing  a  gap  in  the  pleura  as  big  as  a  saucer. 
At  this  moment,  the  lung  receded,  and  the  growth  went  with 
it  a  little  way  back  into  the  chest  ;  immediately,  the  patient 
collapsed,  his  breathing  stopped,  his  pulse  could  not  be  felt ; 
injections  of  ether  and  camphor  were  given,  and  the  danger 
passed  off  as  soon  as  the  growth  was  again  grasped  and 
drawn  forward.  It  was  now  found  to  be  firmly  fixed,  by 
a  broad  base,  to  the  lower  edge  of  the  lung.  The  surgeon 
passed  his  finger  over  the  lung,  and  felt  no  other  growths  in 
it  ;  his  assistant  then  held  the  edge  of  the  lung  forward,  and 
kept  it  compressed,  while  he  transfixed  and  tied  it,  cut  away 
the  growth  with  scissors,  and  closed  the  wound  in  the  lung 
with  a  continuous  suture.  He  then  let  go  the  lung  :  it 
collapsed  at  once  ;  again  the  patient  became  deadly  pale, 
and  gave  no  sign  of  pulse  or  respiration  ;  he  seized  the  lung 
and  drew  it  forward,  and  again  the  patient  revived.  When, 
on  tying  his  last  skin  suture,  the  surgeon  had  finally  to  let  go 
the  lung,  the  patient  once  more  collapsed  ;  and  for  some 
days  after,  he  had  slight  dyspnoea.  Three  days  after  the 
operation,  six  or  seven  ounces  of  serum  were  let  out  from  the 
pleura.  In  March,  1891  (three  and  a  half  years  later)  a 
recurrent  nodule,  beneath  the  scar,  was  removed  ;  a  little  air 

'W.  Miiller,  Ein  Thorax-wand-Lungen  Resection  mit  giins- 
tigem  Verlauf.     "  Deutsch.  Ztschr.  f.  Klin.  Chir.,"  1893,  p.  41. 


lyo  SURGERY    OF    THE    CHEST. 

entered  the  pleura,  but  no  harm  came  of  it.  In  July,  1893, 
the  patient  was  in  perfect  health.  The  growth  was  of  a 
mixed  character,  mostly  bone  and  cartilage  at  its  centre, 
sarcoma  at  its  exterior. 

3.  A  man,  aged  ^7,  who  had  first  noted  the  disease  only 
four  months  earlier,  had  a  very  large  tumour  of  the  ribs  (round- 
celled  sarcoma)  extending  from  the  fifth  rib  on  the  right 
side  down  to  the  lower  border  of  the  thorax,  and  from  the 
edge  of  the  sternum  to  the  lower  angle  of  the  scapula. 
Operation  :  the  sixth  and  seventh  ribs  were  resected  from 
near  the  sternum  backward  for  nearly  their  whole  length  ; 
the  pleura  was  torn,  and,  as  the  growth  had  begun  to  attack 
the  diaphragm,  a  piece  of  the  diaphragm  was  removed,  about 
an  inch  and  a  half  in  diameter  ;  through  the  hole  thus  made, 
the  liver  and  the  intestine  protruded,  and  had  to  be  put 
back  :  the  diaphragm  was  sutured.  The  patient  was  badly 
collapsed,  but  revived  under  injections  of  ether,  and  faradiza- 
tion along  the  phrenic  nerves.  He  died  on  the  fourth  day, 
of  capillary  bronchitis  ;  the  wound  in  the  diaphragm  was 
found  firmly  closed. 

4.  A  man,  aged  29,  in  good  general  health,  had  for  ten 
years  noted  a  growth  on  his  right  side,  in  front  of  the 
shoulder  ;  it  had  of  late  increased  rapidly,  its  lower  part 
had  become  soft,  and  had  been  punctured,  and  fiuid  had 
been  drawn  off.  It  now  extended  from  the  second  rib  down 
to  the  nipple  ;  passed  forward  an  inch  beyond  the  middle 
line,  and  backward  to  the  posterior  axillary  line  ;  it  was 
nodular,  hard  as  cartilage,  fluctuating  on  its  lower  aspect, 
and  almost  as  large  as  a  child's  head.  Operation  :  April 
26th,  1893  :  a  large  flap  was  raised,  including  part  of  the 
pectoral  muscle,  the  third  rib  was  cut  through,  and  the 
growth  was  cleared  with  the  finger,  and  raised  :  it  was  found 


TUMOURS     OF 


Dudon, 
18S9 


Mazzoin, 
1875 


Sex  and 
Age. 


F.    28 


M.  55 


History  and  Symptoms. 


Attributed  to  a  blow : 
only  noted  a  short 
time  before  operation. 


Character  of  Tumour. 


Hard,  slightly  nodular, 
size  of  hen's  egg. 
Enchondroma  of  the 
manubrium. 

Myxo-sarcoma. 


TUMOURS   OF   THE   RIBS   AND   STERNUM.       171 


more  easy  than  had  been  expected  to  strip  the  pleura  off  it, 
except  over  its  lower  posterior  aspect,  where  growth,  pleura, 
and  lung  were  all  adherent  together  ;  at  this  point,  a  piece  of 
the  pleura,  and  a  small  piece  of  the  lung,  were  removed  with 
scissors.  Little  blood  was  lost  ;  pulse  and  breathing  re- 
mained good.  The  day  after  the  operation,  he  had  a  good 
deal  of  dyspnoea  ;  some  suppuration  occurred  ;  he  made  a 
good  recovery.  The  growth  was  cartilaginous,  with  cystic 
degeneration. 

I  give  these  four  cases  to  show  that  the  surgeon  cannot 
be  sure  beforehand  what  he  will  find  during  the  operation  ; 
the  lung  or  the  diaphragm  may  be  involved,  though  the 
breath-sounds  in  the  immediate  neighbourhood  of  the 
growth  appear  perfectly  normal,  and  though  there  be  no 
marked  sign  of  impeded  respiration.  Still,  the  study  of 
a  large  number  of  cases  gives  us  some  help  toward  esti- 
mating the  extent  of  the  disease.  The  whole  subject  has 
lately  been  reviewed  so  thoroughly  and  carefully  by 
Campe,!  that  I  give,  in  a  tabular  form,  some  of  the  cases 
he  has  collected,  and  the  rules  of  diagnosis  he  has 
deduced  from  them.  To  his  collection  of  the  records  of 
other  surgeons,  he  adds  nine  cases — three  of  tumour  of 
the  sternum,  six  of  tumour  of  the  ribs,  that  were  under 
the  care  of  Konig  during  the  years  1882-93. 


'Ueber  Tumoren  der  Knochernen  Thoraxwand. 
Dissertation,  Gottingen,  1894. 


Inaugural- 


THE    STERNUM. 


Operation. 


First  operation,  removed  with 
chisel.  Recurred  in  four  months  ; 
resection  of  sternum  down  to 
level  of  third  rib. 

Resection  of  sternum,  from  manu- 
brium almost  to  ensiform  carti- 
lage, with  pieces  of  the  second, 
third  and  fourth  ribs. 


Result. 


Recovery. 
Three  small 
recurrent  no- 
d  ules  re- 
moved later. 

Death  15th  day 
from  pneu- 
monia and 
bronchitis. 


Remark.s. 


Neither  pleura  nor 
pericardium  was 
opened. 


SURGERY    OF    THE    CHEST. 


Tumours    of   the 


Rekkkence. 


Sex  and 
Age. 


3.  Weinlechrier    F.    53 

Ih82 


4.  Kijster,  1883^  M.  30 


5.  Pteifer,  1884     M.  45 


6.  Konig,  1882 


7.  Konig,  1892 


F.   42 


History  and  Symptoms. 


M.  59 


Since  six  years  old,  had 
noted  a  small  hard 
nodule  over  middle  of 
sternum.  3  years  ago, 
a  soft  growth  arose  in 
connection  with  it. 

Painful  swelling,  right 
border  of  sternum 

Noted  nine  months ; 
rapid,  later  painful. 


Two  and  a  quarter 
years  ago,  began  to 
have  pain ;  first  noted 
swelling  a  year  ago. 
General  health  good, 
no  troubles  of  respi- 
ration or  circulation. 


History  of  injury  three 
years  ago.  Growth 
first  noted  six  months 
ago  ;  rapid  increase  ; 
difficulty  of  breathing 
lately  on  exertion ,  but 
only  then.  General 
health  good. 


Character  of  Tumour. 


Chondro-sarcoma. 


Diagnosed  as  sarcoma. 


Size  of  an  apple ' ;  of 
doughy  consistency. 
.\lveolar  sarcoma. 


Tumour  extended  over 
nearly  the  whole  of 
the  sternum,  and  a 
little  way  into  the 
intercostal  spaces. 
Osteo-sarcoma. 


Growth  extends  across 
sternum  from  second 
to  fifth  ribs  ;  size  of  a 
man's  fist,  nodular, 
somewhat  hard,  ill- 
defined  ;  skin  over  it 
normal ;  no  unusual 
signs  on  auscultation 
or  percussion.  Myxo- 
chond  ro-sarcoma. 


TUMOURS   OF   THE  RIBS   AND   STERNUM. 
Sternum — Continued. 


173 


Ol'ERATION. 


Result. 


Remarks. 


Hard  nodule  (enchondroma)  re- 
moved level  with  sternum  ;  soft 
growth  (colloid  sarcoma)  extir- 
pated. 


Resection  of  right  border  of  ster- 
num, with  pieces  of  third  and 
fourth  right  ribs. 

Resection  of  sternum  with  pieces 
of  second,  third  and  fourth  ribs 
on  both  sides. 


Death  5th  day 
from  pyaemia. 


Recovery  in 
four  weeks. 

Death  a  week 
after  opera- 
tion. 


Growth  freely  exposed  ;  costal  car- 
tilages very  carefully  cleared  and 
elevated,  and  divided  in  the 
following  order  :  second  left, 
second,  third  and  fourth  right. 
Manubrium  now  sawn  across,  re- 
maining costal  cartilages  invol- 
ved carefully  divided,  tumour 
found  projecting  into  mediasti- 
num, cleared  with  great  difficulty. 
One  nodule  of  the  growth  ran 
deep  into  the  mediastinum,  and 
it  was  uncertain  whether  it  had 
been  wholly  removed. 

Growth  freely  exposed  by  raising  a 
large  flap  over  it ;  ends  of  costal 
cartilages  carefully  cleared. 
Second  right  cartilage  divided, 
then  sternum  sawn  across  just 
above  it,  then  third  to  fifth  right, 
and  second  to  fifth  left  cartilages 
divided,  then  lower  part  of  ster- 
num sawn  across.  Considerable  difficulty  in  clearing  its  posterior 
aspect.  Both  internal  mammary  arteries  tied  and  divided  at  operation. 
Right  lung  adherent  to  growth  at  level  of  fourth  rib ;  pleura  opened 
here.     Piece  of  lung  removed  with  growth. 


Recovery. 

Some  suppu- 
ration follow- 
ed in  the 
mediastinum, 
and  gangrene 
of  a  small 
patch  of  skin. 
Operation 
lasted  about 
three  hours. 


Death  the  day 
after  the 
operation. 


Right  pleura  opened. 
Swelhng  was  found 
to  be  a  gumma. 

Right  pleura  opened. 
Haemothorax.  pleu- 
risy, bronchitis, 
pneumonia ;  signs  of 
tubercular  disease 
of  both  lungs.  Se- 
condary growths  in 
liver,  kidneys,  and 
4th  left  rib ;  perfor- 
ation of  oesophagus. 

Patient  died  a  year 
later  of  rheumatic 
fever.  At  the  oper- 
ation, both  the  pleu- 
ra and  the  pericar- 
dium were  opened ; 
they  were  at  once 
plugged  with  strips 
of  gauze,  which  were 
withdrawn  as  the 
last  stitches  were 
tied.  Left  internal 
mammary  artery 
was  tied  at  operat'n. 

Post  mortem,  air  and  a 
considerable  quan- 
tity of  blood  in  right 
pleura.  Dilated 
heart.  Secondary 
growths  in  the 
liver. 


174 


SURGERY    OF    THE    CHEST. 


TUMOURS    OF 


Reference.  '^^^^     History  and  Symptoms.        Character  of  Tumour. 


I.  Weinlechner    M.  37 
i38o 


2.    Ma^s,   1885 


M.  42 


3.  Baldus,  1887     M 


4.  Halm,  1888 


5.  Riesenfeld, 


6.  Marsh,  1890 


7.  Tietze,  xi 


M.  33 


M.  46 


Noted  four  years  ;  but 
after    a     blow    grew 

very  rapidly. 


Noted  many  years ; 
attributed  to  a  blow. 
Was  at  first  small 
and  painless  ;  after  a 
second  injury,  grew 
rapidly  to  enormous 
size,  and  became  very 
painful. 


Two  previous  opera- 
tions during  the 
earlier  part  of  the 
year,  with  resection 
of  rib. 


Slow  growth,  no  pain, 
no  marked  impair- 
ment of  breathing. 


Noted  four  weeks  after 
a  kick  on  the  ribs 
from  a  horse.  Three 
years  slow  growth,  no 
pain. 


Size  of  man's  head ; 
growing  from  third  to 
fifth  right  ribs  ;  hard, 
but  soft  in  places. 
Myxo-chondroma. 

Huge  growth,  16  inches 
across,  from  left  lower 
ribs ;  hard,  elastic, 
very  painful.  Osteo- 
myxo-chondroma. 


Large  growth,  from 
second  to  fourth  left 
ribs,  from  sternum  to 
axilla,  and  from  clavi- 
cle to  nipple.  Myxo- 
chondroma. 

Large  recurrent  growth, 
size  of  two  fists,  from 
lower  ribs.  Myxo- 
fibro-chondroma. 


From  seventh  intercos- 
tal space  to  ninth  rib, 
on  left  side.  Osteo- 
myxo-chondroma. 


From  third  right  rib  ; 
external  swelling 
small,  internal  growth 
size  of  a  man's  fist. 

Large,  elastic,  firm 
growth,  21  inches  in 
circumference,  arising 
from  sixth  -to  eighth 
ribs  on  right  side. 
Giant-celled  sarcoma. 


TUMOURS   OF   THE   RIBS    AND   STERNUM. 
THE     RIBS. 


175 


Oteration. 


Resection  of  the  ribs  involved, 
with  the  pleura,  and  a  piece  of 
the  lung  '  the  size  of  a  saucer.' 
Removal  of  two  small  nodules 
from  the  upper  lobe  of  the  lung. 

Resection  of  four  or  five  inches  of 
ninth,  tenth  and  eleventh  ribs, 
with  the  pleura  belonging  to 
them. 


Resection   of    the 
Pleura  opened. 


ribs    involved. 


Resection  of  sixth  to  tenth  ribs, 
wide  opening  made  into  the 
pleura  ;  diaphragm  wounded,  and 
secured  to  upper  edge  of  external 
wound  ;  growth  adherent  to  peri- 
toneum ;  removal  of  a  piece  of  the 
peritoneum  '  the  size  of  a  saucer.' 

Resection  of  eighth  rib,  and  a  piece 
of  pleura  two  inches  across. 


Resection  of  third  rib,  with  piece 
of  pleura  three  inches  across. 


Resection  of  large  pieces  of  sixth 
to  ninth  ribs ;  diaphragm  adhe- 
rent, and  wounded  during  opera- 
tion. 


Result. 


1     24 
from 


Death 
hours 
purulent 
pleurisy. 


Complete  re- 
covery in 
three  weeks. 


Complete  re- 
covery in 
three  weeks. 


Death  soon 
after  the  op- 
eration. 


Complete  re- 
covery in 
four  weeks. 
No  recur- 
rence, five 
years  later. 


Rapid    recov- 
ery. 


Death  two 
days  after 
operation. 


Remarks. 


Dyspnoea  for  two 
days  after  opera- 
tion ;  highest  temp. 
101-3°. 


Pulse  and  respira- 
tion normal  after 
the  first  24  hours. 


Though  she  had  asth- 
ma, emphysema, 
and  chronic  bron- 
chitis, the  pneumo- 
thorax gave  no 
serious  trouble. 
Lung  had  fully  ex- 
panded when  she 
left  the  Hospital. 

Lung  did  not  collapse, 
but  moved  freely 
during  operation. 

Marked  dyspnoea 
after  operation; 
death  attributed  to 
'  failure  of  the  heart.' 


176 


SURGERY    OF    THE    CHEST. 


Tumours   of   the 


Refeurncp.  "^  '^^^    History  and  Symptoms.       Character  of  Tumour. 


8.  Heisl  1S85 


g.   Helferich, 


10.  Humbert, 


II.  Meyer, 

1887 


12.  Kronlein, 
1883-1888 


13.  Tietze, 


M. 


M.  27 


M.  21 


M.  31 


F.    17 


F.    28 


No  known  cause ;  some- 
what rapid  growth, 
no  pain. 


Noted  after  an  injury. 
Slow  growth,  two 
years'  duration.  At 
times,  would  become 
swollen  and  painful, 
then  subside  again. 

First  operation,  a  year 
ago ;  pleura  was  open- 
ed, and  growth  was 
merely  cut  off  level 
with  the  ribs.  Re- 
curred in  a  few 
months  ;  very  pain  • 
ful ;  pleural  effusion 
on  affected  side. 

Noted  six  months  after 
an  injury ;  rapid, 
painful. 


Tumour  noted  a  year 
and  a  half  before  first 
operation.  Recurred 
six  months  after  first 
operation;  again 
three  years  after 
second  operation ; 
finally,  a  year  after 
third  operation. 

Noted  nine  years,  came 
after  a  blow.  Very 
slow  growth  at  first, 
but  much  more  rapid 
during  each  preg- 
nancy. Painless  at 
first,  but  finally  very 
painful. 


Hard  growth,  size  of 
fist,  to  left  of  sternum, 
over  second  to  fifth 
ribs.     Fibro-sarcoma. 


Firm  nodular  growth, 
size  of  fist,  over  fifth 
to  seventh  ribs  on 
right  side.  Alveolar 
sarcoma. 

Recurrent  growth,  size 
of  chestnut,  over 
seventh  to  ninth  ribs. 
Periosteal  sarcoma. 


Size  of  fist ;  lound- 
celled  sarcoma.  Site 
not  stated. 


Sarcoma  of  sixth  rib  on 
left  side,  size  of  a 
child's  head. 


Hard  growth,  size  of 
two  fists,  arising  from 
fifth  rib  on  left  side. 
Naevoid     osteo-sarco- 


TUMOURS   OF   THE   RIBS   AND   STERNUM. 
Ribs — Continved. 


177 


Operation. 


Resection  of  second  to  fifth  ribs, 
four  inches  each,  and  of  a  small 
part  of  edge  of  sternum. 


Resection  of  sixth  rib.     Pleura  not 
opened. 


Resection  of  seventh  to  ninth  ribs. 
Pleura  freely  opened,  sero-puru- 
lent  fluid  let  out.  Opening  made 
into  diaphragm,  nearly  three 
inches  long. 


Resection  of  ribs  involved  ;  pleura 
opened  so  wide  that  the  whole 
hand  could  easily  be  introduced. 


1883,  Resection  of  sixth  rib; 
growth  removed ;  pleura  not 
opened.  1884,  Resection  of  fifth 
to  seventh  ribs,  very  extensive  ; 
pleura  opened,  adherent  piece  of 
lung  removed.  1887,  Growth 
size  of  fist  ;  resection  of  fifth  rib, 
with  adherent  piece  of  lung. 

Resection  of  fifth  rib ;  pleura 
freely  opened. 


Result. 


Recovery  in  a 
fortnight. 


Recovery. 


Recovery     in 
two  months. 


Remarks. 


Rapid    recov- 
ery. 


Growth  re- 
curred in 
1888,  and  no 
further  oper- 
ation  was 
possible. 


Recovery. 


Pleura  and  pericar- 
dium freely  exposed, 
but  not  opened. 
Marked  dyspnoea 
and  rapid  pulse 
after  operation. 


Recurrence  soon  after 
recovery ;  and  oper- 
ation this  time 
ended  in  death. 


Recurrence  in  six 
months  ;  hernia  of 
lung  beneath  the 
scar.  Recurrent 
growth,  and  portion 
of  lung,  both  re- 
moved; recovery. 

Died  of  pneumonia, 
Nov.  1890. 


lyS 


SURGERY    OF    THE    CHEST. 


Tumours   of   the 


Reference. 


Sex  and 
Age. 


History  and  Symptoms. 


Charactpk  of  Tumour. 


14.  Desguin, 


15.  Witzel, 


M.  41 


M.  30 


16.  Plitt,  1890 


17.  Mikulicz, 
i8qi 


18.  Caro,  1891 


ig.   Konig, 


M.  38 


M.54 


F.   31 


F.   13 


More  than  one  opera- 
tion had  already  been 
performed  for  pri- 
mary or  recurrent 
growths. 


Noted  soon  after  a  very 
severe  injury  ;  pain- 
ful ;  rapid. 


Four  years   duration 
never  painful. 


Rapid  growth,  first 
noted  three  months 
before  operation. 


Growth  noted,  after 
rheumatic  fever,  a  few 
weeks  before  opera- 
tion ;  was  thought  to 
be  abscess,  and  punc- 
tured. Very  feeble 
general  health. 


Spindle- celled  sarcoma 
of  the  ninth  right  rib. 


Sarcoma,  size  of  fist,  of 
tenth  and  eleventh 
ribs. 


Large  growth,  with 
secondary  nodules 
round  it,  over  sixth  to 
ninth  ribs ;  whole  mass 
size  of  fist.     Sarcoma. 

Huge  growth,  size  of 
child's  head,  over 
lower  ribs  on  left  side; 
hard  in  some  places, 
soft  in  others.  Cystic 
myxo  -  chondro-  sarco- 
ma. 

Soft,  elastic  growth 
size  of  fist,  front  of 
right  side  of  chest, 
from  clavicle  to  fourth 
rib.  Periosteal  sar- 
coma, growing  from 
second  rib. 

Growth,  about  size  of 
fist,  left  side,  far  back, 
over  eighth  to  eleventh 
ribs.  Dulness  on  per- 
cussion and  loss  of 
breath  sounds  for 
about  ahand's  breadth 
all  round  it.  Heart 
not  displaced.  Round- 
celled  myxo-sarcoma. 


TUMOURS   OF   THE   RIBS   AND   STERNUM 
Ribs — Continued. 


179 


Ol'ERATlON. 


Resection    of    eighth    and     ninth 
ribs,  with  adherent  pleura. 


Resection  of  ribs  involved,  and  of 
transverse  processes  of  their  two 
vertebras,  also  diseased.  Free 
opening  into  pleura.  Severe 
dyspnoea,  treated  by  converting 
the  pneumothorax  into  hydro- 
thorax,  and  then  slowly  aspira- 
ting the  fluid. 

Resection  of  seventh  to  ninth  ribs, 
six  inches  of  each,  with  adherent 
pleura. 


Free  resection  of  eighth  to  eleventh 
ribs  ;  removal  ot  a  strip  of  dia- 
phragm 3^  inches  long  by  f  inch 
broad.  Severe  dyspnoea  ;  hasmo- 
thorax,  probably  from  wounded 
intercostal  artery,  treated  by 
puncture. 

Resection  of  three  inches  of  second 
rib,  with  adherent  infiltrated 
pleura.  Next  day,  signs  of 
haemothorax;  a  few  ounces  of 
blood-stained  fluid  withdrawn. 


Operation  showed  extensive  malig- 
nant disease,  which  was  only 
scraped  away  so  far  as  possible. 


Result. 


Recovery. 


Rapid    recov- 
ery. 


Recovery. 


Recovery. 


Recovery  in  a 
fortnight. 


Rapid  increase 
of  disease, 
and  death 
three  weeks 
after  opera- 
tion. 


Remarks. 


Pneumothorax  dis- 
appeared within  a 
week  ;  but  lung  did 
not  fully  expand, 
and  liver  rose  above 
normal  level. 

Before  putting  in  the 
last  stitches,  he 
filled  the  pleura  with 
warm  boric  lotion, 
thus  expelling  the 
air  ;  then  closed  the 
wound,  and  slowly 
drew  off  the  lotion 
through  a  catheter. 

Only  slight  collapse 
of  lung.  Two  sub- 
sequent successful 
operations  for  recur- 
rence in  glands. 

Lung  expanded  well. 
Recurrent  nodules 
removed  from  scar, 
nine  months  after 
operation. 


No  trouble  from  pneu- 
mothorax. Three 
subsequent  opera- 
tions next  year  for 
recurrent  nodules, 
and  death  that  year 
from  recurrence  past 
operation. 

Post  mortem,  signs  of 
septic  absorption. 
Mass  of  disease  in 
pleural  cavity,  size 
of  a  man's  head. 


i8o 


SURGERY    OF    THE    CHEST. 


Tumours   of   the 


Reference. 


Sex  and 
Age. 


History  and  Symptoms.       Character  of  Tumouk 


io.    Konig, 


21.  Konig, 
i8gi 


22.  Konig, 

1893 


23.  Konig, 
1893 


F.    26 


M.  34 


F.    30 


M.  5.=; 


Broke  a  rib  a  year  and 
a  half  ago ;  noted 
swelling  there  a  year 
ago.  No  pain,  but 
tenderness. 

Noted  only  six  weeks  ; 
not  painful.  Says  he 
has  a  cough,  and  is 
losing  flesh ;  looks 
thin,  pale,  feeble. 

Noted  a  year ;  slow 
growth,  no  pain. 


Noted  si.K  or  seven 
years  ago  ;  gradual, 
painless  ;  for  the  last 
year  rapid,  and  pain- 
ful on  coughing. 


Below  right  breast,  over 
sixth  to  ninth  ribs,  a 
large  flattened  growth, 
giving  marked  feeling 
of  fluctuation.  Chon- 
dro-myxo-sarcoma. 

Firm,  elastic  growth, 
size  of  large  apple, 
over  seventh  rib  in  an- 
terior axillary  line ;  no 
fluctuation.  Alveolar 
round  celled  sarcoma. 

Very  hard  growth,  size 
of  hen's  egg,  over 
sixth  to  eighth  left 
costal  cartilages,  just 
where  they  join  the 
sternum.  Round- 
celled  sarcoma. 

Firm  hard  growth,  but 
fluctuating  over  lower 
aspect ;  below  right 
nipple,  over  fourth  to 
seventh  ribs.  Cystic 
enchondroma. 


I  have  left  out  a  few  of  Campe's  cases,  which  did  not 
undergo  operation,  or  are  too  briefly  recorded  to  be  of 
value,  or  happened  long  before  we  had  learned  to  avoid 
the  dangers  of  wound-infection,  and  of  carbolic  acid 
poisoning,  which  proved  fatal  to  them.  Among  these 
older  cases,  the  most  famous  is  that  of  Richerand,  who  in 
I  Si  8  operated  successfully  on  a  man  aged  40,  for  tumour 
of  the  ribs  (carcinoma),  removing  four  inches  of  the 
seventh  and  eighth  ribs,  and  eight  square  inches  of 
the  pleura. 

Two  cases  of  cancer  of  the  ribs  secondary  to  cancer  of 
the  breast,  may  be  given  here.    Schede,  after  operation  in 


TUMOURS   OF   THE   RIBS   AND   STERNUM.  i8i 

Ribs — Continued. 


Operation. 


Result. 


Remarks. 


Resection  of  eighth  rib  with  ad- 
herent parietal  and  diaphragm- 
atic layers  of  pleura;  diaphragm 
not  perforated.  Pleura  freely 
opened ;  considerable  dyspnoea 
for  a  few  days. 

Resection  of  seventh  rib,  with  ad- 
herent pleura  ;  lung  found  fixed 
by  old  adhesions  of  upper  lobe. 
No  serious  dyspncea  either  during 
or  after  operation. 

Sub-periosteal  resection  of  the 
cartilages,  2^  inches  of  each.  The 
growth  had  invaded  the  medias- 
tinum, but  was  removed  without 
opening  the  pleura.  Pulsation 
of  right  ventricle  clearly  seen. 

Sub-periosteal  resection  of  fifth 
and  sixth  ribs  ;  pleura  opened ; 
lung  collapsed.  Wound  in  pleu- 
ra sutured,  save  for  a  hole  for 
drainage.  Patient  suffered  in- 
tense shock. 


Recovery      in 
three  weeks. 


Slow  recovery. 


Recovery     in 
three  weeks. 


Death  a  few 
hours  after 
operation. 


Successful  operation 
for  very  extensive 
recurrence,  three 
years  later. 


Very  rapid  recurrence 
and  death. 


There  was  gangrene 
of  a  patch  of  skin 
over  one  of  the  cut 
ends  of  cartilage. 
No  recurrence, 
nearly  two  years 
later. 

Post  mortem,  more 
than  half  a  pint  of 
blood  in  the  pleura. 
Chronic  degenera- 
tive changes  in  heart 
and  lungs. 


1882  for  cancer  of  the  breast,  operated  in  1885  for 
recurrent  disease  involving  the  ribs,  and  resected  them 
over  an  area  five  or  six  inches  in  diameter.  Caro  reports 
the  case  of  a  woman,  aged  55,  whose  breast  had  been  re- 
moved in  t888;  early  in  1892,  recurrent  nodules  were 
removed  on  two  occasions  ;  and  later  in  the  year  recur- 
rence took  place  over  a  wide  area  of  the  ribs.  Free 
resection  was  made  of  two  ribs  :  the  pleura  was  avoided, 
but  a  small  opening  was  made  in  the  pericardium.  Both 
patients  recovered. 

A   careful   study  of  the   records  of  these  tumours  of 
the  ribs  and  sternum  will  give  clearly  their  chief  clinical 


i82  SURGERY    OF    THE    CHEST. 

features  and  their  usual  course.  Several  points  are 
brought  out  very  definitely ;  we  see  that  they  are,  as 
a  rule,  painless,  especially  the  enchondromata,  at  all 
events  till  they  have  attained  a  great  size  ;  that  they  are 
very  often  the  result  of  some  injury ;  that  they  may  for 
many  years  grow  very  slowly,  and  then,  either  spontane- 
ously, or  after  a  blow,  a  puncture,  or  an  incomplete 
operation,  take  on  rapid  growth. 

The  tumours  of  the  sternum  seem  mostly  to  occur  in 
middle  life,  and  tend  toward  some  form  of  sarcoma;  those 
of  the  ribs  occur  in  early  adult  life,  and  have  more  the 
character  of  enchondroma.i  They  may  easily  be  mistaken 
for  chronic  abscess  ;  and  the  still  more  grave  mistake 
may  be,  and  has  been  made,  of  operating  on  a  syphilitic 
gumma  in  the  belief  that  it  is  a  new  growth.  Wide- 
spread adhesion  of  the  pleura,  the  pericardium,  or  the 
diaphragm,  and  extensive  disease  of  the  lung,  may  take 
place  without  giving  rise  either  to  symptoms  or  to 
physical  signs  of  their  presence  ;  and  there  is  seldom  any 
effusion  into  the  pleura.  But  in  a  growth  of  long 
duration,  near  the  heart,  or  over  the  lower  ribs,  one  may 
suspect  that  the  pericardium  or  the  diaphragm  is  in- 
volved, if  there  be  disturbance  of  the  heart's  action,  or 
cough  and  hiccough. 

As  regards  differential  diagnosis,  innocent  growths, 
such  as  lipoma  and  fibroma,  are  extremely  rare,  and 
belong  rather  to  the  soft  parts  of  the  chest-wall  than  to 
the  ribs.  Exostoses  never  attain  any  considerable  size, 
nor  can  one  well  mistake  the  feel  of  them.  Chronic 
abscess  may  very  closely  imitate  a  new  growth ;  and, 
above  all,  a  syphilitic  gumma  may  do  this,  so  that  with 
any  swelling  of  ribs  or  sternum  we  must  always  keep  in 

'  Out  of  20  cases  of  tumours  of  the  ribs  collected  by  Speicher, 
i6  were  enchondroma,  and  4  sarcoma. 


TUMOURS   OF   THE   RIBS   AND   STERNUM.       183 

mind  the  possibility  that  it  is  due  to  syphilis.  Finally, 
malignant  disease  of  the  chest-wall,  receiving  pulsation 
from  the  heart,  has  been  mistaken  for  aneurysm  ;  the 
converse  error  also  has  been  committed. 

The  dangers  that  beset  operation  for  tumours  of  the 
ribs  and  sternum  are  many  and  grave ;  but  the  results  of 
the  last  few  years  are,  on  the  whole,  very  encouraging. 
It  is  the  cases  that  have  been  '  watched '  for  months  or 
years  that  darken  the  results  gained  by  surgery  ;  and 
those  also,  where  the  patient  has  died  either  from  neglect 
of  the  strictest  rules  of  the  antiseptic  method,  or  from 
the  excessive  use  of  carbolic  acid.  If  we  take  Campe's 
tables,  and  follow  the  operation  stage-  by  stage,  we  see 
first  the  need  of  a  very  free  exposure  of  the  growth,  and 
this  is  best  secured  by  a  large  flap,  with  convexity  down- 
ward, of  all  the  soft  parts  over  it.  Next,  unless  the 
growth  be  small,  the  surgeon  may  be  sure  he  will  open 
the  thin,  tense,  adherent  pleura,  however  careful  he  may 
be  to  avoid  it ;  and  he  must  have  fixed  in  his  mind, 
before  the  operation,  the  exact  method  by  which  he  will 
deal  with  this  dangerous  trouble.  He  must  further 
avoid  every  risk  of  haemorrhage,  after  operation,  into  the 
pleural  cavity.  He  must  be  prepared  to  deal  with  an 
adherent  or  diseased  portion  of  the  lung,  the  pericardium, 
or  the  diaphragm.  Indeed,  one  might  make  a  very  long 
list  of  the  risks  that  face  him  during,  and  after,  the 
operation  ;  but  to  do  this  would  be  only  to  re-write  the 
records  I  have  already  quoted.  Happily,  the  subject 
has  also  a  brighter  side  to  it ;  and  there  are  plenty 
of  successful  cases  to  encourage  the  surgeon,  especially  if 
the  growth  has  not  long  been  noted,  and  if  he  is  prepared 
to  meet  all  the  risks  that  have  been  enumerated,  and  . 
others  that  may  arise  during  the  first  few  days  after  the 
operation. 


184 


CHAPTER  XIV. 

PLEURAL  EFFUSIONS,    OTHER    THAN   EMPYEMA. 

We  have  come  at  last  to  the  frontiers  of  the  land  of  the 
physicians.  There  has  long  been  a  desultory  sort  of 
border  warfare  over  this  portion  of  their  vast  territory  ; 
and  here  we  might  stop  to  count  what  gains  the  surgeons 
have  won  from  them,  so  far  as  our  subject  is  concerned, 
and  to  consider  whether  we  have  any  good  hope-  of 
further  conquest.  But  history  tells  us  plainly  that  the 
physicians  have  done  as  much  as  the  surgeons  to  advance 
the  surgery  of  the  chest,  and  rather  more ;  and  age 
after  age  thousands  of  lives  have  been  lost  because 
the  surgeons  who  ought  to  have  saved  them  were 
blinded  by  all  sorts  of  false  theories  and  idle  specu- 
lations. As  we  should  expect,  the  three  men  who  have 
done  most  for  the  surgery  of  the  chest  are  the  first  great 
physician,  the  man  who  first  used  the  stethoscope,  and  the 
discoverer  of  the  antiseptic  method  ;  and  the  three  names 
of  Hippocrates,  Laennec,  and  Lister  are,  indeed,  those 
that  stand  out  above  all  the  rest.^  Next  to  them,  we 
may  put  Trousseau  and  Dieulafoy  for  France,  Schuh. 
Skoda  and  Frantzel  for  Germany,  Bowditch  for  America 

'  And  o'er  the  plain,  where  the  dead  age 
Did  its  now  silent  warfare  wage — 
O'er  that  wide  plain,  now  wrapt  in  gloom, 
Where  many  a  splendour  finds  its  tomb, 
Many  spent  fames  and  fallen  nights — 
The  one  or  two  immortal  lights 
Rise  slowly  up  into  the  sky 
To  shine  there  everlastingly. 

Matthew  Arnold. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    185 

and  Douglas  Powell  and  Godlee  for  England ;  and 
Ambroise  Fare's  name  shall  stand  last,  and  out  of  place, 
that  it  may  be  next  to  that  of  the  surgeon  who  has 
written  so  gracefully  in  honour  of  him.  Hippocrates  and 
his  school  treated  empyema  by  free  incision ;  they  re- 
moved a  piece  of  rib,  let  out  the  pus,  and  kept  the  wound 
open.  Their  art,  like  all  Greek  art,  was  lost ;  and  there 
remained  no  clear  rule  of  practice,  nothing  but  a  chaos 
of  wrong  speculations,  and  the  loss  of  an  incalculable 
number  of  lives.  Between  Hippocrates  and  Laennec, 
save  Ambroise  Pare,  and  Drouin  (15th  century),  who 
first  put  a  trochar  and  cannula  into  the  chest,  and,  per- 
haps, one  or  two  others,  there  are  no  immortal  names, 
so  far  as  our  subject  goes.  What  Hippocrates  could  do, 
in  the  pure  air  of  Greece,  was  fatal  when  it  was  done  in 
a  mediaeval  hospital,  or  in  the  infected  wards  of  the 
hospitals  a  hundred  years  ago  ;  and  if  anyone  will  read 
the  death-rates  after  operations  at  the  Maison  Dieu  about 
that  period,  or  how  the  women  would  pray  on  their  knees 
not  to  be  admitted  to  a  certain  lying-in  ward  of  a  great 
hospital  at  Vienna,  he  will  understand  how  the  minds 
of  surgeons  got  to  be  set  on  avoiding  operation,  not  on 
perfecting  it,  and  they  followed  their  own  imaginations, 
and  laid  the  blame  on  the  patient,  or  the  air,  or  on  any- 
thing except  themselves.' 

The  pleural  effusions,  other  than  empyema,  are  of 
several  kinds  ;  there  is  the  ordinary  effusion  of  pleurisy, 
the  passive  effusion  (hydrothorax)  in  the  last  stages  of 
cardiac  or  renal  disease,  the  effusions,  which  may  be 
mixed    with    air  or  blood,   of   malignant    disease   or    of 

'  He  who  desires  to  read  the  history  of  the  subject,  should 
consult  Trousseau's  "  Clinical  Medicine,"  vol.  iii.  (Syd.  Soc. 
Trans.),  Frantzel  (Ziemssen's  Handbuch,  1875),  Gerhardt  (Wien. 
Klin.  Wchnschr.),  1891,  p.  215,  and  Evans,  "St.  Thomas'  Hosp. 
Reports,"   1871. 


i86  SURGERY    OF    THE    CHEST. 

advanced  tubercular  phthisis  ;  there  are  the  true  '  haemor- 
rhagic  pleurisies,'  and  there  is  chylothorax,  from  injury 
or  disease  of  the  thoracic  duct ;  and  pleurisy  by  trau- 
matic infection,  as  where  the  pleura  is  accidentally 
opened  during  an  operation.  All  these  forms  of  effusion 
may  need  surgical  treatment :  let  us  then  begin  with  the 
ordinary  effusion  after  acute  pleurisy,  keeping  to  the 
surgical  aspect  of  it.  At  what  stage,  and  by  what 
method,  should  the  surgeon  interfere  ?  Having  duly 
considered  this  question,  let  us  then  note  the  possible 
harm  that  may  follow  interference. 

Ordinary  Acute  Pleural  Effusion. 

The  rule  that  a  simple  serous  effusion  after  acute 
pleurisy'  should  be  for  two  or  three  weeks  left  untouched, 
has  of  late  years  been  disputed ;  and  it  is  a  very 
pleasant  occupation  to  trace  its  history ;  especially  for  a 
surgeon  who  has  never  understood  the  exact  reasons  for 
its  authorit}-.  In  so  late  as  the  fifth  edition  of  Sir  Thomas 
Watson's  great  work,  we  read,  '  In  simple  pleurisy,  punc- 
ture of  the  chest  ought  never,  in  my  judgment,  to  be 
performed,  unless  the  life  of  the  patient  is,  or  seems  to 
be  in  jeopardy,  from  the  continual  presence  of  the  liquid 
within  the  thorax.'  Frantzel,  in  1875,  recommended  that 
you  should  not  puncture  the  chest  in  simple  pleurisy 
before  the  end  of  the  third  week,  or  until  the  effusion 
reaches  the  third  rib,  unless,  for  some  reason,  you  are 
driven  to  it ;  Dr.  de  Havilland  Hall,  in  1876,  said:  'If, 
after  giving  other  methods  a  fair  trial — and  I  consider 
three   weeks  to    be   ample  time — there   were   then   no 

'  Dr.  Washbourn's  paper,  "  Cases  of  Pleurisy  caused  by  the 
Pneumococcus,"  in  the  Med.  Chir.  Soc.  Trans.,  1894,  P-  ^79^ 
gives  valuable  guidance  for  the  recognition  of  those  cases  of 
acute  pleurisy  which  most  closely  imitate  pneumonia. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    187 

signs  of  absorption  to  any  marked  extent,  I  would  advise 
puncture.'  Gerhard t,  in  1891,  says  that  puncture  ought 
not  to  be  made  before  three  weeks  after  the  beginning  of 
the  illness,  unless  there  is  some  special  cause  for  it ;  and 
Dr.  Clifford  Allbutt,  in  1894,  says  :  'As  a  general  rule, 
if  an  effusion  rises  much  above  the  angle  of  the  scapula, 
and  al;)ides  in  this  quantity  or  more  for  two  or  three 
weeks,  in  spite  of  adequate  treatment,  it  must  be  drawn 
off,  whether  the  patient  be  embarrassed  by  it  or  not.' ' 

It  is  plain  that  the  practice  of  waiting  till  the  patient 
was  in  danger  of  death  came  through  the  fault  of  those 
surgeons  who,  by  the  use  of  trochars  not  sterilized,  con- 
verted a  serous  effusion  into  a  purulent  one  ;  or,  even  if 
it  stopped  short  of  this,  yet  the  puncture  was  followed 
by  increase  of  fever,  and  by  a  rapid  fresh  accumulation 
of  the  fluid  up  to  a  level  as  high  as  it  was  before,  or 
higher.  To  wait  till  the  patient  is  nearly  dead  is  a  rule 
that  may  be  dismissed  with  a  reference  to  a  case  recorded 
by  Frantzel  :  '  In  1867,  a  case  came  under  my  care 
where  operation  was  indicated,  but  as  it  was  late  in  the 
evening,  I  put  it  off  to  the  next  morning.  That  night, 
the  patient  suddenly  called  for  help,  and  the  nurse,  on 
coming  to  the  bedside,  found  him  dead.  Th.e.post  mortem 
examination  showed  the  whole  of  the  left  pleura  full  of 
a  serous  effusion  ;  the  displacement  of  the  organs  was  so 
great  that  the  vena  cava  inferior  was  kinked  almost  to 
a  right  angle,  where  it  passes  through  the  diaphragm.' 
We  are  now  more  likely  to  go  to  the  other  extreme,  and 
to  puncture  the  chest  even  for  effusions  of  moderate  size, 
which  neither  trouble  the  patient  nor  endanger  his  life 


'For  references,  see  "St.  Bartholomew's  Hosp.  Reports," 
1876;  Quain's  Dictionary,  new  ed.,  p.  474;  "  Wien.  Klin. 
Wchnschr.,"  1891,  p.  215;  also  "Brit.  Med.  Journ.,"  July  13, 
1895,  and   "  Lancet,"   Nov,  2,  1895. 


i88  SURGERY    OF    THE    CHEST. 

or  his  lung.  But  it  is  certainly  better  to  be  too  soon 
than  too  late.  It  is  not  likely  that  the  lung  will  be 
damaged  by  our  waiting,  or  that  a  few  days'  delay  will 
make  any  difference  by  allowing  adhesions  to  form,  or 
by  increasing  the  risk  of  thrombosis  of  the  pulmonary 
artery  ;  still,  these  things  are  not  impossible ;  and  in  any 
doubt,  the  decision  should  be  in  favour  of  operation. 

The  choice  of  the  method  of  operation  at  the  present 
day  is  between  aspiration  and  incision  ;  putting  aside 
cases  of  emergency,  where  relief  must  be  given  by  what- 
ever method  comes  to  hand.  Simple  puncture  with  an 
ordinary  trochar  and  cannula  will  not  always  serve  instead 
of  aspiration  ;  it  may  be  successful,  or  it  may  fail  to 
withdraw  a  sufficient  quantity  of  fluid.  '  There  is  always 
this  one  drawback  to  simple  puncture  without  aspiration, 
that  a  good  quantity  will  flow  only  so  long  as  the  internal 
pressure  is  higher  than  the  pressure  of  the  atmosphere ; 
v>'hen  the  two  become  equal,  then  it  is  only  on  forced 
expiration,  such  as  coughing,  that  a  few  drops  of  fluid 
can  be  let  out,  even  though  there  are  many  pints 
in  the  chest ;  I  have  frequently  observed  this.  In  one 
case,  that  of  a  man,  aged  75,  who  was  unable  to  give  a 
good  cough,  hardly  a  drop  flowed.  And  it  is  impossible 
to  tell  beforehand  the  degree  of  the  internal  pressure : 
generally,  it  is  highest  in  recent  effusions  with  displace- 
ment of  the  organs  :  but  this  rule  is  not  absolute — even 
in  such  cases,  I  have  failed  to  draw  off  more  than  a  few 
drops  of  fluid  by  simple  puncture  without  aspiration.' 
(Frantzel.) 

The  choice,  then,  lies  between  aspiration  and  incision  ; 
and  it  is  only  in  the  last  year  or  two  that  we  have  had 
any  choice  at  a!l  in  the  matter.  In  April,  1895,  ^^r. 
West  published  a  case  of  pleural  effusion  cured  by 
incision  after  several  aspirations  had  failed,  and  in  July  a 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    189 

similar  case  was  published  by  Mr.  Rutherford  Morison; 
and  in  November,  1895,  three  cases  were  reported  at  a 
meeting  of  the  Medical  Society  by  Dr.  A.  Wilson,  of 
Leytonstone,  of  free  incision  without  previous  aspiration. 
Of  course,  in  a  case  of  emergency,  one  must  open  the 
pleura  with  whatever  instruments  are  to  hand ;  but, 
except  for  emergency,  I  cannot  see  that  incision  has 
any  advantage  over  aspiration  ;  it  is  more  alarming,  and 
more  painful,  for  the  patient,  and  affords  at  least  a 
possibility  of  troubles  which  cannot  follow  aspiration  ;  it 
is  true  that  it  avoids  other  troubles  that  aspiration  may 
bring  with  it,  but  I  think  the  balance  of  advantages  is 
in  favour  of  aspiration,  and  incision  should  be  kept  for 
cases  where  there  is  urgent  necessity  for  immediate  oper- 
ation, or  where  aspiration  has  failed. 

And  as  regards  the  point  at  whicli  the  needle  is  to  be 
introduced,  we  need  not  review  the  vast  array  of  former 
opinions :  some  of  them  rested  on  doctrines  of  pressure 
and  of  equilibrium,  which  have  no  immediate  application 
to  practical  surgery.  One  must  not  go  too  low,  for  fear 
of  wounding  the  diaphragm,  and  because  fibrinous  masses 
may  block  the  needle  here;  but  even  these  apprehensions 
may  be  more  theoretical  than  real.  We  may  take  Mr. 
Godlee's  rule  for  empyema :  '  Opposite  the  ninth  rib,  just 
outside  the  angle  of  the  scapula,'  or,  as  Dr.  Clifford 
Alibutt  puts  it,  'The  eighth  space,  in  a  line  with  the  angle 
of  the  scapula,  or  a  little  outside.'  But  in  particular  cases, 
there  may  be  reasons  for  choosing  some  other  point. 

Risks  of  Aspiration.     Sudden  QEdema  of  the 
Lung. 

These  slight  operations  are  not  wholly  free  from  risk. 
One  is  hardly  likely  to  wound  the  diaphragm  or  the 
abdominal  organs — nor,  if  one   did,  would  it  be  much 


igo  SURGERY    OF    THE    CHEST. 

consolatioi  to  remember  that  the  same  thing  was  done 
by  Laennec  himself.  Nor  is  there  much  excuse  for  a 
surgeon  who  wounds  the  lung;  this  has  often  been  done, 
and  I  know  of  a  case  where  it  ended  in  death.  If 
the  needle  gets  blocked,  and  cannot  be  cleared  with  a 
stilette,  it  is  better  to  puncture  in  a  fresh  place  than  to 
try  to  clear  the.  needle  by  syringing  down  it.  Nothing 
but  harm  can  come  of  withdrawing  the  effusion  too 
rapidly  ;  what  the  Germans  call  '  aspiration  in  a  storm.' 
Though  there  is  no  certain  evidence  that  aspiration, 
however  violent,  can  actually  rupture  the  lung,  yet  it 
may  cause  it  to  bleed,  may  excite  bleeding  from  the 
pleura  or  from  recent  adhesions,  or  may  provoke  painful 
coughing  ;  above  all,  a  rapid  aspiration  is  dangerous, 
because  it  may  bring  about  sudden  faintness,  or  may 
even  set  up  that  most  dangerous  condition  known  as 
acute  oedema  of  the  lung,  or  serous  oedema,  the  'expecto- 
ration albumineuse  '  of  Terrillon. 

The  syncope  that  may  follow  the  too  rapid  escape  of  a 
pleural  effusion  may  be  compared  with  that  slighter 
degree  of  faintness  which  may  follow  the  sudden  empty- 
ing of  a  distended  bladder,  or  even  the  evacuation  of  an 
over-loaded  bowel.  Inasmuch  as  it  comes  of  simple  loss 
of  intra-pleural  pressure,  it  is  somewhat  different  from 
those  strange  cases  of  syncope  that  follow  irrigation  of 
the  cavity  of  an  empyema,  which  are  given  in  chapter  xvii. 
Though,  as  a  rule,  it  occurs  during  or  immediately  after 
the  operation,  it  may  be  delayed,  as  in  a  case  recorded 
by  Sir  William  Broadbent,^  where  a  man,  aged  62,  with 
a  large  left  pleural  effusion,  died  suddenly  three  and  a 
half  Jiours  after  aspiration.  Should  the  patient  become 
faint  during  the  withdrawal  of  the  fluid,  the  surgeon  ought 

'"  Clin.  Soc.  Trans,"  1877,  x.  24. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    191 

at  once  to  leave  off",  and  not,  as  one  authority  has  advised, 
to  wait  till  he  revives,  and  then  go  on. 

Serous  oedema  of  the  lung,'  with  profuse  albuminous 
sputa,  is  a  disaster  so  strange  and  so  alarming,  and  the 
explanation  of  it  is  of  such  interest,  that  it  may  be  worth 
while  to  spend  some  time  over  it.  Happily,  it  is  rare  ; 
unhappily,  nothing  can  be  done  either  to  foresee,  to 
prevent,  or  to  alleviate  it.  In  its  worst  form,  it  is  a  sudden 
swamping  of  the  expanding  lung  by  the  transudation  of 
serous  fluid  into  its  substance  ;  an  invasion  of  the  air- 
vesicles,  so  general  and  so  rapid,  that  the  patient  may 
die  almost  at  once,  a  profuse  frothy  serous  expectoration 
obstructing  his  air-passages  and  suffocating  him.  In  a 
less  severe  degree,  he  suffers  oppression,  distress,  and 
difficulty  of  breathing,  he  is  somewhat  cyanosed,  and  is 
seized  with  a  paroxysmal  cough,  with  profuse  expectora- 
tion, perhaps  a  quart  altogether,  of  clear  frothy  serous 
fluid  ;  the  attack  may  last  some  hours,  or  even  a  whole 
day,  slowly  abating  its  intensity  till  the  lung  again  acts 
naturally.  In  the  least  severe  degree,  there  is  but  slight 
dyspnoea,  no  marked  distress,  and  a  less  profuse  expecto- 
ration, but  of  the  same  characteristic  clear,  yellowish, 
thin,  frothy  fluid,  separating  on  standing  into  yellowish 
froth  on  the  surface,  then  serous  alkaline  fluid  giving 
an  abundant  coagulum  of  albumen,  then  a  deposit  at 
the  bottom  of  the  vessel  of  epithelial  cells  and  blood 
corpuscles.  During  the  attack,  if  it  be  at  all  severe,  fine 
crepitant  rales  may  be  heard  in  great  abundance,  especially 
over  the  base  of  the  lung. 

'  This  account  of  it  is  an  abstract  of  Terrillon's  delightful  essay, 
"  De  I'expectoration  albumineuse  apres  la  thoracentese."  Paris, 
Bailliere  et  Fils,  ^873.  See  also  a  good  case  by  Kovacs,  Ueber 
einen  Fall  von  acutem  Lungencedem  nach  Thoracocentese, 
"  Wien.  Klin.  Wchnschr.,"  i8gi,  p.  41.-  Also  "Clin.  Soc. 
Trans.,"  April,  1896. 


192  SURGERY    OF    THE    CHEST. 

There  is  usually  an  interval,  from  ten  minutes  to  an 
hour,  between  the  completion  of  the  operation  and  the 
onset  of  the  expectoration ;  in  two  instances,  there  was 
no  interval ;  in  two,  it  lasted  several  hours.  So  long  as 
it  lasts,  minutes  or  hours,  the  patient  appears  to  be  well, 
and  to  enjoy  full  relief  from  the  operation.  The  duration 
of  the  attack  may  be  only  a  quarter  of  an  hour,  or 
several  hours,  or  even,  as  in  one  case,  two  days ;  the 
total  quantity  of  the  expectorated  fluid  may  come  to  two 
or  three  pints. 

There  was  nothing  in  the  history  of  the  cases 
collected  by  M.  Terrillon,  in  the  character  of  the  pleural 
effusions,  or  in  the  course  of  the  operations,  to  account 
for  it ;  most  of  them  were  ordinary  serous  effusions  after 
acute  pleurisy  ;  only  three  out  of  the  twenty  were  passive 
effusions  (hydrothorax)  due  to  disease  of  the  heart.  But 
it  is  especially  to  be  noted  that  the  effusions  were  large, 
on  an  average  three  and  a  half  or  four  pints,  and  that  in 
every  case  they  were  withdrawn  from  the  chest  rapidly 
and  in  a  continuous  stream. 

The  old  explanations  (i,)  that  the  lung  was  wounded 
with  the  trochar  so  that  the  pleural  effusion  got  into, 
the  bronchi  ;  (2,)  that  there  was  a  fistula  in  the  lung, 
which  was  opened  up  by  the  sudden  expansion  of  it,  thus 
admitting  the  pleural  effusion  into  the  bronchi;  (3,) 
that  in  some  mysterious  way  the  pleural  effusion  was 
suddenly  absorbed  into  the  lung,  and  thus  into  the 
bronchi ;  none  of  these  three  theories  will  stand  examina- 
tion. There  is,  indeed,  only  one  possible  explanation, 
that  the  rapid  expansion  of  the  lung  is  followed  by  some 
vaso-motor  change  in  the  walls  of  its  capillary  vessels, 
allowing  the  serum  of  the  blood  to  escape  into  the  alveoh. 

In  2  of  the  21  cases  collected  by  M.  Terrillon,  the 
patient  died,   almost  at  once.     'Immediately  after  the 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    193 

operation  he  was  relieved,  had  no  cough,  and  seemed  in 
every  way  doing  well.  About  twenty  minutes  later,  he 
was  suddenly  seized  with  dyspnoea,  which  rapidly 
became  intense,  with  a  hacking  cough  and  profuse  frothy 
expectoration  ;  then  came  an  agonized  struggle  for  breath; 
then,  after  a  few  minutes  of  terrible  anxiety,  during  which 
his  breathing  was  almost  arrested,  the  fluid  poured  in  a 
stream  from  his  mouth,  he  became  cyanosed,  and  died.' 
In  the  19  cases  not  fatal,  the  distress,  cough,  and  other 
signs  of  the  fluid  in  the  lung  were  of  different  intensity 
and  duration  in  different  cases,  but  in  all  they  were 
well  marked. 

The  case  published  by  Kovacs  is  worth  careful  study. 

The  patient,  a  woman,  aged  58,  given  to  drink,  and 
generally  unsound,  had  a  left  pleural  effusion  ;  aspiration, 
done  slowly,  drew  off  a  pint  and  a  half,  and  was  then 
stopped  on  account  of  a  violent  fit  of  coughing.  A  few 
minutes  later,  the  cough  returned,  and  she  began  to 
expectorate  a  quantity  of  yellowish  serous  frothy  fluid, 
which  became  more  and  more  profuse,  with  dyspnoea, 
and  a  pulse  that  could  hardly  be  felt ;  fine  crepitant  rales 
and  moist  sounds  were  heard  over  both  lungs,  but  chiefly 
over  the  left.  In  spite  of  active  stimulation  she  became 
collapsed,  the  fluid  was  no  longer  coughed  up,  loud  rales 
in  the  larger  bronchi  were  now  audible,  even  without 
applying  the  ear  to  the  chest.  In  spite  of  this  alarming 
condition,  she  pulled  through  the  night,  and  was  a  little 
better  next  morning  ;  sputa  still  copious,  serous,  frothy, 
tinged  with  blood,  and  loaded  with  albumen  ;  the  urine 
contained  albumen,  and  hyaline  and  fatty  casts.  On  the 
third  day,  the  sputa  were  scanty,  blood-stained,  then  viscid 
and  rusty,  like  pneumonic  sputa.  In  the  first  48  hours, 
there  was  collected  over  a  pint  of  the  serous  fluid  sputa  ; 
specific  gravity  loii,  loaded  with  albumen.     Seven  or 


194  SURGERY    OF    THE    CHEST. 

eight  weeks  later  it  was  again  necessary  to  operate ;  only 
about  a  third  of  a  pint  was  very  slowly  drawn  off;  but  all 
the  former  dyspnoea  and  profuse  albuminous  expectora- 
tion again  occurred ;  after  this,  nothing  more  was 
ventured,  and  she  died  in  very  great  distress  ten  days 
later. 

It  might  be  possible,  in  such  a  case  as  this,  to  use 
Southey's  trochars  at  the  second  operation,  with  very 
gradual  syphon-drainage.  During  the  attack  itself,  one 
can  but  keep  the  patient  going  with  brandy,  hypodermics 
of  strychnine,  and  other  stimulants  ;  no  good  is  likely  to 
come  of  artificial  respiration ;  the  administration  of 
oxygen,  if  it  were  available,  would  probably  be  of  great 
value. 

Secondary  Pleural  Effusions.^ 

We  come  next  to  those  cases  of  secondary  serous 
effusion  which  follow  diseases  other  than  pleurisy.  Such 
effusions  are  often  mingled  with  blood,  or  with  debris  of 
the  primary  disease,  if  it  be  in  the  lung ;  in  this  case, 
air,  as  well  as  fluid  (hydro-pneumothorax),  may  be 
present  in  the  pleura.  In  the  last  stages  of  chronic 
cardiac  or  renal  disease,  in  the  exhaustion  of  advanced 
malignant  disease,  or  after  one  of  the  specific  fevers,  a 
passive  serous  effusion  may  occur  in  one  or  both  pleurae, 
without  fever,  or  much  pain  or  coughing,  unmixed  with 
blood,  free  from  fibrinous  deposits  or  loose  cdagula,  a 
true  dropsy  of  the  pleura,  now  called  hydrothorax  ;  a 
condition  more  often  noted  in  the  J>osi  mortem  room  than 
needing  treatment  in  the  wards  ;  what  used  to  be  called 

'  See  Frantzel  loc.  cit. ;  Netter,  "  Wien.  Med.  Presse,"  1892,  p. 
33  ;  Litten,  "  Verhandl.  d.  Congr.  f.  Inn.  Med.,"  1885-86,  p.  417; 
Lawson  Tait,  "Med.  Chir.  Trans.,"  1892,  p.  109;  Freyhau, 
"  Wien.  Med.  Presse,"  1892,  p.  185. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    195 

'water  on  the  chest,'  and  was  in  the  days  before  Laennec 
often  assumed  to  be  present,  and  to  be  the  cause  of 
death,  in  cases  where  it  was  absent ;  and  was  often 
confounded  with  the  effusion  of  acute  pleurisy.  The 
fever,  cough,  and  pain  of  acute  pleurisy, '  are  absent ; 
both  pleurae  are  often  affected,  and  thus  there  is  probably 
no  marked  displacement  of  the  organs  ;  the  presence  of 
old  adhesions  may  limit  or  subdivide  the  effusion,  but 
should  it  rise  high  the  results  of  its  pressure  are  very 
severe,  as  the  patient  is  already  enfeebled  by  disease. 
The  treatment  must  of  necessity  be  limited  to  relief  of 
the  distress  by  aspiration  ;  and  should  the  heart's  action 
be  feeble,  even  this  will  not  be  without  some  risk  :  in  one 
of  Terrillon's  cases,  aspiration  for  hydrothorax  secondary 
to  disease  of  the  heart  was  followed  by  acute  oedema 
of  the  lung :  when  it  became  necessary  to  repeat  the 
operation,  every  precaution  was  taken  to  strengthen 
the  action  of  the  heart,  and  this  time  there  was  no 
oedema. 

In  tubercular  phthisis,  a  minute  opening  may  come 
in  the  surface  of  the  lung,  from  softening  of  a  small  focus 
of  the  disease,  and  the  pneumothorax  that  may  follow 
may  be  attended  by  a  non-purulent  pleural  effusion,  dis- 
tinct from  that  form  of  empyema  which  follows  the 
giving  way  of  a  cavity  in  the  lung.  Netter  examined 
the  effusion  in  sixteen  cases  of  this  non-purulent  tuber- 
culous hydro-pneumothorax.  In  every  one,  the  tubercle- 
bacillus  was  present,  but  the  ordinary  micro-organisms  of 


^  The  cough  in  the  early  stage  of  acute  pleurisy  is  not  due  to 
direct  irritation  of  the  pleura — for  this,  as  Nothnagel  showed  by 
experiment,  does  not  cause  cough ;  but  to  the  beginning  of  com- 
pression of  the  lung  by  the  effusion.  The  intercostal  pain,  or 
stitch  in  the  side,  is  an  early,  definite,  and  constant  sign.  Valleix 
found  it  in  40  cases  out  of  46.  Both  cough  and  pain  tend  to 
disappear  as  the  effusion  grows  larger. 


196  SURGERY    OF    THE    CHEST. 

suppuration  were  absent ;  and  guinea-pigs  inoculated 
with  the  fluid  developed  general  tuberculosis.  This 
non-purulent  effusion  may  become  purulent  by  subsequent 
infection,  by  the  giving  way  of  a  cavity  in  the  lung,  and 
then  the  ordinary  micro-organisms  of  suppuration  and 
putrefaction  will  be  present,  together  with  the  tubercle- 
bacillus  ;  but  there  are  cases  where  it  has  remained 
non-purulent,  and  has  been  improved  or  even  cured  by 
simple  aspiration — a  true  tuberculous  hydro-pneumo- 
thorax,  a  direct  inoculation  of  the  pleura,  as  if  for  an 
experiment,  with  the  tubercle-bacillus.  One  may  get  a 
similar  effusion,  but  without  pneumothorax,  in  primary 
tuberculosis  of  the  pleura,  a  disease  very  rare  at  any  age, 
but  even  more  so  in  childhood  than  in  late  life. 

Next  to  be  considered  are  those  pleural  effusions  that 
follow  the  invasion  of  the  lung  by  strange  parasitic 
organisms,  spirilla,  or  protozoa ;  a  group  of  cases  belong- 
ing rather  to  pathology  than  to  surgery,  but  useful 
here  as  emphasizing  the  need  of  careful  microscopic 
examination  of  the  fluid  in  any  unusual  case  of  pleural 
effusion.  In  the  case  of  acute  oedema  after  aspira- 
tion, quoted  from  Kovacs,  the  pleural  fluid  contained 
the  micro-organism  called  '  Curschmann's  spirillum,' 
found  also  in  cases  of  gangrene  of  the  lung,  chronic 
bronchitis,  and  bronchiectasis.  In  a  case  of  hydro- 
pneumothorax,  Litten  found  in  the  fluid  flagellate 
protozoa,  resembling  spermatozoa,  and  the  same  organ- 
isms have  also  been  found  in  gangrene  of  the  lung,  and, 
by  Grimm,  in  a  case  of  abscess  of  the  lung  with  abscess 
of  the  liver.  Of  vegetable  parasites,  aspergillus,  such  as 
one  sometimes  sees  in  the  external  auditory  meatus,  has 
been  found  in  the  lung' ;    and  Freylau  has    published 

'Dr.  Bristowe  and  Dr.  Wheaton,  "Path.  Soc.  Trans.,"  vols. 
V.  and  xli.     See  also  chapter  xxvi. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    197 

the  case  of  a  man,  aged  22,  with  a  hsemorrhagic  effusion 
in  the  lett  pleura,  in  whose  sputa  were  found  masses  of 
mycelial  growth  with  conidia.  As  regards  actinomycosis 
of  the  lung,  the  disease  itself  is  not  here  to  be  considered  ; 
and  it  tends  rather  to  adhesions  of  the  pleura  than  to 
effusions  into  it ;  or  the  effusion  is  purulent  from  the 
very  first.  Pleural  effusions,  purulent  or  sero-sanguin- 
eous,  have  been  recorded  by  Mr.  Shattock  and  Dr. 
Delepine  in  cases  of  actinomycosis  of  the  liver,  but 
these  were  due  to  general  septicaemia,  or  to  infection  by 
contiguity. 

Litten's  case  is  worth  reading,  not  because  of  the  flagel- 
late protozoa  found  in  the  fluid,  but  for  the  marked 
physical  signs  that  it  presented  : — 

A  man,  aged  34,  after  '  inflanimation  of  the  lungs,'  was 
found  to  have  an  enormous  effusion  into  the  right  pleura, 
reaching  up  to  the  second  rib,  and  displacing  the  diaphragm 
and  the  heart.  Simple  puncture,  without  aspiration,  let  out 
more  than  five  pints  of  serous  fluid,  to  his  great  relief.  Eight 
days  later,  the  fluid  had  re-collected  ;  when  he  stood  upright, 
it  reached  as  high  as  the  third  rib  in  front ;  when  he  lay 
down,  it  only  reached  to  the  sixth  rib.  Now,  too,  he  com- 
plained of  a  peculiar  sound  in  his  chest,  which  his  wife  had 
pointed  out  to  him,  as  it  was  heard  when  he  moved  in  bed  ; 
a  gurgling  note,  such  as  one  gets  by  shaking  water  in  a  half- 
empty  bottle;  and  when  he  shook  himself,  a  splashing  sound 
{siiccussio  Hippocratis)  was  plainly  heard,  even  at  some 
distance.  The  opening  in  the  lung,  probably  due  to  rupture 
of  a  softened  spot  by  the  withdrawal  of  the  fluid,  was  now 
beneath  the  level  of  the  fresh  collection  of  fluid,  and  was 
closed  by  its  pressure,  like  a  valve  ;  at  times,  one  could  hear 
air-bubbles,  having  escaped  from  the  lung  and  risen  through 
the  fluid,  break  on  the  surface  of  it  with  a  metallic  splashing 
sound  ;  and  when  the  second  effusion  was  withdrawn,  air 
could  be  heard  whistling  through  the  opening  in  the  lung, 
or  could  be  made  to  whistle  through  it  by  further  exhausting 
the  aspirator. 

The  serous  effusions  that  may  attend  these  rare  infec- 


igS  SURGERY    OF    THE    CHEST. 

tive  processes  in  the  lung  are  often  bloodstained  ;  and 
every  suspicious  effusion,  and  the  patient's  sputa,  should 
be  carefully  and  repeatedly  examined  with  the  microscope. 
But  a  blood-stained  serous  fluid  is  more  likely  to  be  due, 
not  to  these,  but  to  tubercular  phthisis  or  malignant 
disease.  This  is  not  an  absolute  rule  ;  the  chance  rup- 
ture of  an  old  adhesion  may  stain  the  fluid  with  blood  ; 
or  an  effusion  in  an  old  person  may  have  blood  in  it, 
without  either  tubercular  or  malignant  disease ;  or  a 
chronic  pleural  effusion  may  contain  old  broken-down 
blood,  as  in  a  case  of  double  haemorrhagic  pleurisy,  of 
long  standing,  with  blood  and  cholestearin  in  the  fluid, 
reported  by  Dr.  Churton,  in  the  "Clinical  Society's 
Transactions"  for  1882.  Still,  a  hsemorrhagic  effusion  is, 
almost  certainly,  a  sign  either  of  tubercular  or  malignant 
disease  of  the  lung  or  pleura,  at  whatever  age  it  occurs. 
Thus,  HofmokU  gives  a  case  of  myxo-sarcoma  of  the 
pleura,  in  a  child,  only  3^  years  old,  with  blood-stained 
fluid  in  the  pleura.  In  a  case  of  'diffuse  endothelial 
cancer'  of  the  pleura  in  a  man,  aged  42,  Rossier^  drew 
off  blood-stained  fluid,  of  specific  gravity,  1013,  contain- 
ing a  quantity  of  albumen,  a  trace  of  sugar,  blood 
corpuscles,  and  a  quantity  of  degenerate  epithelial  cells. 
It  would  be  easy  to  give  a  number  of  references  to 
the  blood-stained  effusions  of  malignant  disease ;  but  I 
am  not  sure  that  the  effusions  m  cancer  of  the  pleura 
secondary  to  scirrhus  of  the  breast  are  so  often  blood- 
stained, as  those  in  primary  sarcoma  of  the  pleura  or  of 
the  lung.  In  a  case  of  my  own,  where  I  had  repeatedly 
to  aspirate  the  pleura  for  effusion  due  to  recurrent  cancer 


'  Beitrage  zur  Lungenchirurgie,   "  Wien.  Med.  Presse,"   1892, 
p.  1904. 

^Travaux  de  I'lnstitut  Pathologique  de  Lausanne,  Jena,  1895. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    199 

after  removal  of  the  breast,  the  fluid  was  not  even  tinged 
with  blood. 

A  haemorrhagic  effusion  may  occur  in  cases  of  abdomi- 
nal tumour,  and  is  an  almost  certain  proof  that  the 
abdominal  disease  is  malignant,  and  has  invaded  the 
diaphragm.  But  even  this  rule  has  found  its  exception. 
]\Ir.  Lawson  Tait\  after  giving  a  case  of  haemorrhagic 
left  pleural  effusion,  due  to  medullary  cancer  of  the  ovary, 
with  fungating  secondary  growth  on  the  pleural  surface 
of  the  diaphragm,  and  after  referring  to  many  similar 
cases,  gives  a  case  of  simple  fibrous  tumour  of  the  ovary, 
in  a  patient,  aged  36,  ending  in  recovery  after  operation, 
where  there  was  double  haemorrhagic  effusion  ;  in  the 
right  pleura,  blood;  in  the  left,  nearly  five  pints  of  blood- 
stained serum  at  the  first  aspiration,  and  four  pints  of 
pale  serous  fluid  unmixed  with  blood,  at  the  second. 

In  tubercular  disease,  as  Moutard-Martin  has  shown 
in  his  very  valuable  essay,  "  Etude  sur  les  Pleuresies 
Hemorrhagiques  "  Paris,  1878,  a  haemorrhagic  effusion  is 
a  sign  of  the  acute  miliary  non-ulcerative  form  of  the 
disease,  never  of  the  common  ulcerative  form.  He  gives 
notes  of  nineteen  cases  :  of  these,  in  two  only  w^as  the 
effusion  so  large  as  to  make  puncture  necessary.  All  the 
patients  died  in  Hospital,  the  great  majority  within  three 
or  four  weeks  of  admission. 

These  secondary  pleural  effusions,  and  the  cases  I 
have  quoted,  both  those  that  piove  the  accepted  rules  of 
pathology,  and  those  that  are  exceptions  to  them — at 
least  agree  in  one  respect,  that  they  emphasize  the  need 
of  very  careful  microscopic  examination  of  the  fluid  and 
sputa,  in  every  case  of  pleural  effusion  that  is  in  any  way 
unusual  or  suspicious. 

'  "  Med.  Chir.  Soc.  Trans.,"  1892,  p.  109. 


200  SURGERY    OF    THE    CHEST. 

Chylothorax.i 

There  are  a  few  recorded  cases,  where  from  injury  or 
disease  of  the  thoracic  duct,  the  chyle  has  passed  into 
one  or  both  of  the  pleural  cavities.  The  condition  is  so 
rare,  that  we  have  only  to  note  its  possibility,  and 
to  remember  that,  if  the  opening  in  the  duct  remains  un- 
closed, the  patient  will  surely  die  of  slow  emaciation. 
Some  of  the  older  cases,  supposed  to  be  chylothorax, 
appear  to  have  been  really  empyema ;  and  it  is  also 
possible  to  mistake  for  true  chyle  the  turbid  fluid,  mixed 
with  degenerate  epithelial  cells  and  other  debris,  that 
may  come  with  tubercular  or  malignant  disease  of  the 
pleura.  Wounds  of  the  thoracic  duct  in  the  neck  during 
deep  operations  in  its  neighbourhood-  have  often  been 
recorded  ;  but  of  direct  wounds  of  the  duct  within  the 
chest  we  really  know  nothing.  But  there  are  one  or  two 
cases  of  indirect  injury  of  this  part  of  the  duct  by  a 
severe  fall,  or  by  a  crushing  of  the  chest ;  and  where 
there  is  no  history  of  any  injury  to  account  for  the  giving 
way  of  the  duct,  we  must  suppose  that  some  acute  or 
chronic  ulceration  or  obstruction  has  brought  about  first 
thinning  and  then  laceration  of  it. 

I.  A  man,  aged  35,  was  crushed  between  the  wall  and 
the  heavy  roller  of  a  machine,  in  such  a  manner  that  /u's 
spine  was  forcibly  extended  and  bent  far  back,  and  he  was 
fixed  for  some  time,  screaming  with  pain,  before  he  could  be 
set  free.     No  serious  injury  was  discovered  at  the  time  ;  but 


'See  Port,  "  Deutsch.  Ztschr.  f.  Chir.,"  1894,  xxxix.,  p.  572  ; 
Neuenkirchen,  "Wien.  Klin. Wchnschr.,"  i89i,p.638;  Weischer, 
*'  Deutsch.  Ztschr.  f.  Chir.,"  1894,  p.  487 ;  Keen,  Philadelphia, 
1894;  Kirchner,  "Arch.  f.  Klin.  Chir.,"  1885;  Boegehold, 
"  Arch,  f   Klin.  Chir.,"  1893 

=  I  have  heard  of  a  fatal  case  of  chylothorax,  with  solid  oedema 
of  the  arm,  after  severe  and  repeated  operations  on  a  boy  for  the 
removal  of  enlarged  axillary  glands. 


PLEURAL  EFFUSIONS,  OTHER  THAN  EMPYEMA.    201 

three  days  later,  he  complained  that  he  had  pain  on  breath- 
ing ;  next  day  his  breathing  was  laboured,  and  some  blood- 
stained fluid  was  withdrawn  from  the  right  side  of  his  chest, 
but  without  giving  him  much  relief.  About  a  week  later, 
reddish-white  milky  fluid  was  withdrawn,  and  was  recognised 
as  chyle,  and  he  was  sent  to  the  Hospital.  On  admission, 
he  was  well-nourished,  free  from  fever  ;  face  slightly  cya- 
nosed,  breathing  laboured  ;  signs  of  effusion  in  lower  part  of 
right  pleura.  Preliminary  puncture  drew  off  reddish-white 
milky  fluid  ;  the  needle  was  left  in  as  a  guide,  a  piece  of  rib 
was  resected,  and  between  four  and  five  pints  of  thin  milky 
fluid  were  let  out,  free  from  blood-clot  or  masses  of  fibrin, 
and  the  cavity  was  drained.  The  fluid,  under  the  microscope, 
was  found  to  be  almost  wholly  globules  of  fat  of  different 
sizes,  with  a  few  white  and  red  blood  cells  ;  it  was  perfectly 
sterile.  The  lung  expanded  rapidly  ;  the  dressings  were 
soaked  through  the  day  after  the  operation,  but  not  after- 
ward ;  the  drain  was  left  out  on  the  third  day  ;  he  made  an 
uninterrupted  recovery.  His  rapid  healing  (since  it  is  not 
likely  that  he  had  a  double  duct,  or  that  any  sort  of  collateral 
circulation  of  the  chyle  could  be  established)  must  be  attribu- 
ted to  closure  of  the  rent  in  the  duct,  either  by  pressure  of 
the  effusion,  or  by  alteration  in  the  position  of  the  parts  from 
expansion  of  the  lung. 

2.  A  little  girl,  aged  9,  received  a  contusion  of  the  front 
of  the  chest,  at  the  level  of  the  thii^d  ribs.  In  the  course  of 
the  next  fortnight,  there  appeared  signs  of  right  pleural 
effusion — cyanosis,  sweatings,  dilatation  of  the  alee  nasi, 
inability  to  lie  down,  fulness  of  right  side  of  chest  up  to  third 
rib,  displacement  of  heart  and  liver  ;  temperature  normal. 
Puncture  in  the  fifth  right  space  let  out  nearly  a  quart  of 
milky  fluid,  which,  under  the  microscope,  was  found  to  be 
chyle.  Ten  days  later  there  was  again  marked  dyspnoea,  but 
under  treatment  with  warm  baths  and  gentle  purgatives,  the 
child  improved,  and  made  a  complete  recovery. 

3.  A  woman,  aged  47,  had  chronic  chylothorax  ;  at 
different  times  each  pleura  had  been  affected  ;  the  disease 
always  ran  its  course  without  fever,  and  the  fluid  always  re- 
collected, in  one  pleura  or  the  other,  after  aspiration.  That 
the  case  was  one  of  true  chylothorax,  and  not  of  pleural 
effusion  with  admixture  of  debris  from  tubercular  or  malig- 
nant disease,  was  shown  by  the  microscope  and  by  analysis. 
There  was  no  history  of  injury,  no  fluid  in  the  abdominal 
cavity  ;  it  must,  therefore,  be  supposed  that  the  duct  had 
given  way  after  some  inflammation  of  its  walls. 


202  SURGERY    OF  THE    CHEST. 

Kirchner  and  Keen  have  collected  between  them 
twenty  cases  of  wound  of  the  duct,  but  we  are  here 
concerned  only  with  its  thoracic  portion.  In  wounds  of 
its  cervical  portion,  by  a  stab,  or  in  deep  operations  on 
the  left  side  of  the  neck,  the  fluid  that  escapes  is  clear 
and  pale  ;  the  patient  has  been  kept  without  food  before 
the  operation,  or  it  is  a  lymph-trunk  that  has  been 
wounded,  not  the  duct  itself;  in  chylothorax,  the  fluid 
is  opaque  like  milk,  and  coagulates  on  removal  into  a 
firm  gelatinous  clot.  Of  the  twenty  cases,  four  were 
injuries  of  the  cervical  portion,  all  during  an  operation  ; 
six  were  abdominal  effusion  ;  nine  were  chylothorax,  and 
one  was  effusion  of  chyle  into  the  mediastinum.  Of  dis- 
ease, as  a  cause  of  chylothorax,  we  know  very  little ;  the 
duct  may  be  blocked  with  a  calculus,  or  with  tubercular 
disease  ;  one  case  of  each  kind  has  been  recorded. 

Boegehold,  in  a  series  of  experiments  on  dogs,  in  two 
instances  made  a  transverse  wound  of  the  duct  at  its 
entrance  into  the  veins ;  pneumothorax  followed,  but  no 
chylothorax,  and  the  wound  was  healed  with  a  fibrinous 
deposit  round  it.  In  three  instances,  he  wounded  the 
duct;  chylothorax  followed,  and  death  in  a  few  days  from 
compression  of  heart  and  lung.  In  one,  he  first  tied 
the  duct  in  the  neck,  then,  on  the  fourth  day,  opened  the 
pleura,  found  the  distended  duct,  and  made  a  very  small 
wound  in  it.  The  animal  was  killed  three  days  later ; 
the  wound  was  found  sealed  with  a  small  red  fibrinous 
clot,  and  very  little  chyle  had  escaped. 

The  pressure  within  the  thoracic  duct  is  slight,  and 
the  duct  has  some  power  of  muscular  contraction — it 
has  been  found,  two  hours  after  death,  that  a  firm  and 
lasting  contraction  of  its  walls  follows  the  application  of 
electricity  from  an  induction-coil.  Experiment  shows 
that  the  wound  in  the  duct  will  soon  be  healed  with  a 


PLEURAL  EFFUSIONS.  OTHER  THAN  EMPYEMA.    203 

fibrinous  dot,  if  only  circumstances  allow  it.  It  appears, 
therefore,  that  one  should  treat  a  case  of  chylothorax  by 
absolute  rest,  forbidding  milk  and  all  food  containing  fat, 
and  by  withdrawing  a  portion  only  of  the  effusion  to 
relieve  pressure,  leaving  the  rest.  I  can  find  nothing  to 
show  that  an  attempt  has  ever  been  made  to  do  more 
than  this,  or  that  it  would  be  justifiable. 


Note  A. — Gilbert,  of  Geneva,  on  the  strength  of 
Debove's  observation  that  the  effusion  in  tuberculous 
patients  contains  products  analogous  to  if  not  identical 
with  tuberculin,  has  tried  using  this  organic  fluid  to 
arrest  the  very  disease  that  gave  rise  to  it.  In  a  case  of 
tuberculous  pleurisy  with  effusion,  having  examined  the 
fluid  with  a  Pravaz  syringe,  he  withdraws  the  needle  part 
of  the  way,  then  thrusts  it  into  the  soft  tissues,  and  here 
makes  a  subpleural  injection  of  the  fluid.  He  and 
others  have  used  this  method  in  21  cases,  and  report 
that  19  were  thus  cured  :  but  I  do  not  know  what  certain 
proof  he  had  that  actual  tuberculous  disease  of  the 
pleura  was  the  cause  of  the  effusion. 

Note  B. — There  are  two  valuable  papers  on  Chylo- 
thorax, by  Dr.  Sidney  Martin  and  Dr.  Turney,  in  the 
"Pathological  Society's  Transactions,"  for  1891  and 
1893.  Ii^  one  case,  there  was  occlusion  of  the  left 
subclavian  and  internal  jugular  veins :  in  the  other, 
probably  blocking  of  the  duct  by  a  cancerous  embolus 
from  cancer  of  the  pylorus. 


204 


CHAPTER     XV. 

EMPYEMA. 

It  is  hard  to  attempt  the  great  subject  of  empyema,  or  to 
present  in  a  proper  order  even  a  small  part  of  the  vast 
literature  that  has  gathered  round  it.  The  only  way  to 
make  these  chapters  useful  is  to  put  in  the  foreground 
those  difficulties  and  abnormalities  that  we  must  be 
prepared  to  meet,  rather  than  those  cases,  my  own  or 
others,  that  ran  a  smooth  and  uneventful  course,  and  to 
note  such  things  only  as  have  a  direct  bearing  on  ques- 
tions and  methods  of  surgical  treatment. 

History. 

If  we  look  again  at  history,  we  find  whole  ages  of 
neglect  or  perversion  of  the  truth;  and  it  is  impossible 
to  understand  how  the  Hippocratic  treatment  of  empyema 
became  so  hopelessly  lost,  when  we  read  the  description 
of  it  in  the  works  of  Hippocrates  himself.  The  teaching 
of  Hippocrates  was  as  follows  :  Having  carefully  washed 
your  patient  with  warm  water,  you  must  seat  him  on  a 
firm  chair,  and  then,  while  your  assistant  steadies  his 
hands,  you  must  gently  shake  him  by  the  shoulders,  in 
the  hope  of  obtaining  a  splashing  sound  in  the  affected 
side  of  the  chest.  Operation  should  not  be  performed 
before  the  fifteenth  day  after  the  beginning  of  his  illness. 
An  incision  must  be  made  through  the  skin,  where  the 
pain  and  the  swelling  are  most  evident,  and  then  the 
pleura  must  be  opened,  either  by  trephining  the  rib,  or 
with   a   sharp    instrument,    or   with    the   actual    cautery. 


EMPYEMA.  205 

When  a  sufficient  quantity  of  pus  has  been  let  out  (and 
those  who  suffer  from  empyema  or  dropsy  of  the  chest 
are  sure  to  die  if  you  rapidly  evacuate  the  pus  or  the 
water),  you  must  keep  the  wound  open  with  a  strip  of 
Hnen  cloth,  secured  with  a  thread.  This  strip  must  be 
removed  daily,  that  the  remainder  of  the  pus  may  run 
out.  On  the  tenth  day  after  the  operation,  you  must 
irrigate  the  cavity  with  warm  wine  and  oil,  for  the 
purpose  of  cleansing  the  surface  of  the  lung ;  these 
irrigations  must  be  made  twice  a  day.  Finally,  when 
the  discharge  has  become  thin  and  serous,  you  must 
keep  a  small  rod  of  metal  in  the  wound,  using  a  smaller 
size  from  time  to  time,  till  the  whole  wound  has  healed. 

If  it  be  true  that  Galen  invented  an  aspirating  syringe, 
this  was  probably  the  beginning  of  the  evil ;  the  Hippo- 
cratic  operation  fell  into  disrepute,  and  there  was  no 
method  to  take  its  place :  incision,  either  with  the  knife 
or  with  the  actual  cautery,  was  almost  wholly  abandoned, 
save  by  some  of  the  Arabian  physicians.  By  the  time 
of  the  Renaissance,  with  the  return  to  Greek  art  and 
literature,  it  was  too  late  to  go  back  to  Hippocrates. 
Surgery  had  become  embarrassed  by  the  bad  results  of 
septic  wounds,  and  it  was  held  to  be  as  dangerous  to  let 
air  into  the  pleura  as  to  leave  an  effusion  unrelieved;  nor 
was  the  difference  between  serous  and  purulent  effusions 
properly  recognized.  Thus  it  happened  that  our  art 
drifted,  in  spite  of  Ambroise  Pare  and  Guy  de  Chauliac, 
into  that  disastrous  period  when  empyema  was  treated  by 
simple  puncture ;  and  not  even  Laennec  could  save  it. 
The  doctrine  that  puncture  for  a  serous  effusion  would 
convert  it  into  a  purulent  effusion,  and  that  the  entry  of 
a  few  air-bubbles  into  the  pleura  might  set  up  a  fulmin- 
ating suppuration,  blocked  the  way ;  and  blocked  it  still 
might  be,  but  for  Lister.     The  history  of  the  treatment 


2o6  SURGERY    OF    THE    CHEST. 

of  empyema,  from  Hippocrates  to  Lister,  would  justify  a 
revival  of  the  oath  of  Hippocrates,  'in  purity  will  I 
practise  my  art,'  if  it  were  understood  that  the  purity 
must  be  not  only  a  virtuous  life,  but  also  a  method  of 
operating. 

For  example,  so  late  as  1872,  M.  Bouchut  published, 
as  an  instance  of  good  and  profitable  surgery,  a  case  of 
empyema  in  a  boy  aged  nine,  cured  in  sixteen  months 
after  fifty-eight  punctures.  In  another  case,  he  punctured 
the  chest,  in  eleven  months,  a  hundred  and  twenty-two 
times.  Lilly  records  a  case  where  he  made  fifty-six  punc- 
tures. Gimbert,  in  a  child  eleven  years  old,  made 
seventy-four  punctures  in  nine  months,  obtaining  a  grand 
total  of  thirty  pints  of  pus.  And  the  worst  of  it  all  is, 
that  out  of  forty-eight  patients  thus  tormented,  only  six 
were  cured. 

Nor  did  free  incision,  before  Lister,  fare  much  better. 
Out  of  twelve  cases,  under  the  care  of  Velpeau,  not 
one  recovered ;  out  of  fifty  cases,  under  the  care  of 
Dupuytren,  all  but  two  died  ;  and  Sir  Astley  Cooper 
complained  that  he  '  could  never  get  a  single  cure.' 

Here  are  three  cases,  less  than  twenty  years  ago,  whose 
lives  might  have  been  saved  if  they  had  been  under  the 
care  of  Hippocrates. 

1.  A  man,  aged  33,  was  admitted  to  Hospital,  in  the  first 
stage  of  acute  pleurisy,  on  Oct.  25th,  1881.  Duringthe  next 
eight  weeks  he  was  punctured  thirteen  times,  giving  a  grand 
total  of  eighteen  pints  of  pus-  Four  days  after  the  last  punc- 
ture, a  small  tube  was  passed  into  the  chest  through  a  small 
hole  made  with  a  trochar.  '  In  spite  of  irrigation,  signs  of 
purulent  absorption  continued,  the  discharge  began  to  smell 
gangrenous,  the  patient  got  steadily  worse,  and  died  on 
March  7th,  1882.  The  pos^  mortem  examination  showed  a 
large  cavity,  its  walls  not  yet  much  thickened  ;  the  lung  was 
not  wholly  collapsed ;  the  kidneys  showed  commencing 
amyloid  disease.' 

2.  A  man,  aged   40,  was  admitted  to  Hospital,  on  the 


EMPYEMA .  207 

seventh  day  of  an  acute  pleurisy,  on  Nov.  27th,  1877. 
Durinjj  the  next  eleven  weeks,  he  was  punctured  fifteen 
times,  giving  a  grand  total  of  sixteen  pints  of  pus.  By  the 
time  he  had  been  punctured  five  times,  the  effusion,  sero- 
fibrinous at  first,  had  become  wholly  purulent  ;  by  the  time 
he  had  been  punctured  fourteen  times,  it  was  putrid  and 
mixed  with  gas.  Now  at  last  an  incision  was  made,  and  the 
cavity  washed  out.  '  Two  years  after  admission,  healing 
appeared  complete,  when,  on  December  7th,  1879,  he  was 
suddenly  carried  off  by  urii;mic  convulsions.'  Fos?  mortem^ 
marked  amyloid  disease  of  liver  and  kidneys. 

3.  A  man,  aged  51,  was  admitted  to  Hospital,  seven  weeks 
after  the  onset  of  acute  pleurisy,  on  Oct.  3rd,  1887.  During 
the  next  seventeen  weeks  he  was  punctured  nine  times,  giving 
a  grand  total  of  nineteen  pints  of  pus.  Abscesses  formed  at 
the  seats  of  puncture.  The  last  puncture  let  out  gas  with 
the  fluid.  Three  days  later,  an  incision  was  made,  and  the 
cavity  washed  out.  '  But  the  patient  was  already  very  feeble, 
exhausted  by  many  months  of  profuse  suppuration  :  in  a  few 
days  he  was  carried  off  by  an  attack  of  erysipelas  starting 
around  the  incision.' 

It  is  sometimes  said  that  surgeons  fifty  years  hence 
will  think  as  little  of  oiu-  results  as  we  think  of  the 
methods  of  fifty  years  ago.  So  far  as  regards  the  surgery 
of  the  chest,  this  is  utterly  untrue.  Fifty  years  ago,  it 
had  risen  above  the  horizon,  it  is  now  nearly  at  its 
zenith.  Indeed,  it  is  possible  that  we  may  see  its 
upward  movement  checked ;  there  are  signs  that  some 
of  the  operations  that  have  been  proposed  and  performed 
for  apical  phthisis  and  for  bronchiectasis  are  falling  out 
of  favour  with  surgeons. 

Bacteriology. 

But  we  are  concerned  at  present  with  empyema,  and 
the  first  thing  to  consider  is  the  natural  history  of  the 
disease.  From  the  bacteriological  pomt  of  view,  an 
account  of  empyema  could  be  written  according  to  the 
natural  history  of  the  different  micro-organisms  present 


2o8         SURGERY    OF    THE    CHEST. 

in  the  fluid. i  In  simple  serous  eifusion,  according  to 
Kracht,  no  micro-organisms  are  present ;  in  empyema 
following  pneumonia,  the  active  micro-organism  is  the 
pneumococcus  of  Frankel ;  in  the  early  stage  of  this 
form  of  empyema,  this  alone  may  be  found;  and  since  it 
has  but  a  limited  term  of  life,  it  may  fail  to  overcome 
the  resistance  of  the  tissues,  and  may  die,  and  the 
effusion,  to  which  it  has  given  rise,  may  undergo 
degenerative  changes,  and  finally  be  absorbed.  It  is 
certain  that  an  empyema  after  pneumonia,  especially  if 
it  be  of  small  extent,  or  in  a  child,  may  be  absorbed. 
Pel2  records  three  cases,  all  of  them  small  circumscribed 
empyemata,  toward  the  posterior  part  of  the  chest :  two 
were  after  pneumonia ;  in  the  third,  the  cause  of  the 
disease  was  doubtful.  In  all,  the  diagnosis  was  confirmed 
by  puncture  :  all  became  absorbed,  and  it  is  certain  that 
none  of  them  broke  into  the  lung  or  the  alimentary  canal. 
Bouveret'^  records  a  similar  case.  After  a  time,  even  if  the 
pneumococcus  be  at  first  the  only  organism,  other  forms 
of  hfe  outnumber  it — streptococci  and  staphylococci,  the 
active  organisms  in  all  ordinary  cases  of  empyema.  A 
special  form  of  bacillus  has  been  found  by  M.  Bouchard 
in  the  blood,  and  in  the  pleural  effusion,  of  those  cases 
of  very  rapid  septic  pleurisy,  with  acute  swelling  of  the 
spleen,  high  fever,  delirium,  and  a  typhoidal  condition, 
first  described  by  Frantzel  in   1877.*     The  bacillus  of 


'  See  Dr.  Bayard  Holmes,  "  Journ.  Amer.  Med.  Ass.,"  April 4, 
1891;  and  Immermann,  "Verhandl.  d.  Congr.  f.  Inn.  Med."  Wien, 
1890,  p.  ig. 

^  "  Zstchr.  f.  Klin.  Med.,"  Berlin,  1890,  xvii.,  p.  199. 

3"  Traite  de  rEmpyeme,"  Paris,  1888.  The  possible  absorp- 
tion of  a  small  passive  empyema  of  this  nature  is  of  course  only 
a  curious  fact  in  pathology,  not  a  reason  against  operating. 

4  For  full  account  and  references,  see  Bouveret,  "Traite  de 
I'Empyeme,"  1888,  p.  419, 


EMPYEMA.  209 

typhoid  (Eberth's  bacillus)  has  been  found  in  pleural  effu- 
sions after  typhoid  fever.  References  to  work  recently 
done  in  America  on  the  bacteriology  of  empyema,  will  be 
found  in  a  valuable  paper  by  Dr.  White  and  Dr.  Wood,  in 
the  'Therapeutic  Gazette,'  Detroit,  Aug.  15,  1894  In 
those  strange  cases  of  empyema  where  the  effusion  is  a 
thin,  dark,  turbid,  horribly  offensive  gangrenous  fluid  — 
the  so-called  'putrid  empyema' — higher  forms  of  life  are 
found ;  chains  of  bacteria,  leptothrix,  various  amoebae. 
And  mention  has  already  been  made  of  the  presence  of 
spirilla  and  of  flagellate  bodies  in  some  secondary  serous 
effusions,  and  of  the  combination  of  micro-organisms  in 
tubercular  empyema. 

There  are  other  considerations  in  the  natural  history  of 
empyema  that  belong  to  bacteriology.  The  pericardium, 
the  pleura,  and  the  peritoneum  are  all  alike  in  structure 
and  in  function,  yet  they  differ  widely  in  their  power  of 
resisting  infection;  and  this  Dr.  Bayard  Holmes  explains 
by  saying  that  the  peritoneum,  being  always  in  close 
proximity  to  infective  material  in  the  alimentary  canal, 
has  acquired  a  power  of  resistance  higher  than  that  of 
the  pleura  or  the  pericardium.  Again,  by  what  process 
do  the  organisms  of  suppuration  gain  access  to  the  pleura, 
when  we  know  that  the  lung-tissue  is  'almost  as  imper- 
vious to  germs  as  the  wad  of  cotton  with  which  we 
stop  our  test-tubes  ? '  These,  and  the  like  subjects, 
belong  to  bacteriology ;  but  the  facts  that  I  have  quoted 
as  to  the  variety  of  organisms  found  in  serous  and 
purulent  effusions  show  the  value  of  making  careful 
microscopic  examination  of  the  fluid  in  all  unusual 
cases. 

But  we  are  now  taking  a  surgical  view  of  empyema:  and 
it  is  difficult  to  know  where  to  begin,  or  how  to  present 
in  the  right  order  what  is  most  useful  to  the  surgeon  in 

14 


210         SURGERY    OF    THE    CHEST. 

the  literature  on  this  subject.^  Perhaps  it  will  be  best  to 
take  first  the  general  character  and  signs  of  empyema ; 
next,  the  course  it  tends  to  follow  when  left  to  itself.  The 
operation,  and  the  difficulties  that  may  attend  or  follow 
it,  and  the  cases  of  chronic  empyema  and  their  treatment, 
require  separate  chapters. 

The  General  Character  of  Empyema. 
That  empyema  is  not  a  rare  disease  of  the  chest,  and 
that  it  is  often  fatal  in  spite  of  surgery,  is  shown  by 
the  statistics  lately  published  here  and  abroad.  Thus, 
Immermann  has  published  74  cases,  and  Hofmokl  60; 
Konig  had  76  cases  in  twelve  years;  Pel,  of  Amsterdam, 
had  100  cases  in  eight  years;  and  in  Great  Ormond 
Street  Hospital,  during  thirteen  years,  1880-1892,  there 
were  214  cases.  Pel,  writing  in  1890,  believed  that 
the  disease  is  on  the  increase.  Our  estimate  of  the 
mortality  from  it  must  vary  according  as  we  include  or 
exclude  the  numerous  troubles  that  are  more  or  less 
a  part  of  it.  Bouveret,  in  1888,  collected  175  cases, 
with  55  deaths;  Konig,  in  1891,  published  his  76 
cases,  with  only  lo  deaths;  Hofmokl  (1889),  of  his  60 
cases,  lost  28  ;  but  of  these,  no  less  than  13  died  of 
tubercular  disease,  6  of  pneumonia,  3  of  pericarditis,  3 
of  peritonitis,  and  i  each  of  amyloid  disease,  heart 
failure,  and  malignant  disease.     Foltanek,^  in  1891,  pub- 

'  See  especially  Bouveret,  "  Traite  de  I'Empyeme,"  Paris,  1888. 
Immermann,  "Die  Behandlung  der  Empyeme,"  ix.  Congress  f. 
Inn.  Med.  Wien.,  1890  ;  Pel,  Ueber  die  Behandlung  der  Pleural- 
Empyeme,  "  Ztschr.  f.  Klin.  Med.,"  Berlin,  1890,  xvii. ;  Schede, 
"  Die  Behandlung  der  Empyeme,"  ix.  Congress  f.  Inn.  Med. 
Wien.,  1890;  Konig,  "Wien.  Klin.  Wchnschr."  1891  ;  Hofmokl, 
"  Klin.  Zeit  und  Strait  Fragen,  Wien,"  18S9,  vol.  iii.  Of  English 
surgeons,  Mr.  Godlee  and  Mr.  Pearce  Gould  (British  Medical 
Assoc,  Nottingham,  1892),  and  Mr.  Pitts'  Lectures,  "  Lancet," 
Oct.  1893.     Other  references  are  given  v/here  necessary. 

^  "  Jahrb.  f.  Kinderheilk,"  xxxi.,  3. 


EMPYEMA.  211 

lished  21  cases  of  empyema  in  children,  treated  by 
incision  without  resection,  with  only  4  deaths.  Immer- 
mann  (1890),  of  his  74  cases,  lost  20  ;  but  17  of  the  20 
died  from  tubercular  disease,  or  septic  infection,  or  other 
causes  than  the  empyema  itself.  Dr.  Lewis  Marshall  ^ 
(1895)  gives  45  cases,  at  all  ages,  with  7  deaths;  Dr. 
Cautley-  (1895)  gives  84  cases,  all  children,  with  14 
deaths ;  Mr.  Pitts  ^  gives  two  lists — 86  cases,  at  all  ages 
(St.  Thomas's  Hospital,  1880-1892),  with  20  deaths — and 
214  cases  at  Great  Ormond  Street  during  the  same 
period,  with  39  deaths.  It  is  the  complications  of  the 
disease  that  drive  its  death-rate  up  still  to  15  or  20  per 
cent.;  were  it  not  for  these,  one  might  reckon  it  at  10  or 
12  per  cent. 

Age  must  be  taken  into  account.  Of  Hofmokl's  60 
cases,  25  were  under  ten  years  old,  and  23  between 
twenty-one  and  forty  years  old.  If  we  take  children 
only,  we  see  that  the  youngest  are  in  most  danger  of 
death  :  thus,  of  54  fatal  cases  at  Great  Ormond  Street,  6 
were  under  one  year  old;  r7,  between  one  and  two  ;  11, 
between  two  and  three  ;  8,  between  three  and  four ;  6, 
between  four  and  five  ;  3,  between  five  and  six;  3,  above 
six  ;  and  Dr.  Coutts'*  has  recorded  43  cases  of  empyema 
in  children  under  two  years  old,  with  27  deaths,  a  mor- 
tality of  63  per  cent. 

Sex  need  not  be  taken  into  account;  the  disproportion 
is  no  greater  than  we  should  expect  from  the  more 
constant  exposure  of  men  to  the  chances  of  pleurisy 
and  pneumonia,  and  is  not  found  among  children.  Of 
Hofmokl's  60  cases,  of  all  ages,  42  were  male,  and  18 
were  female. 


'  "Lancet,"  Dec.  21,  1895.         '  "  Lancet,"  Feb.  2,  1895. 
3  "  Lancet,"  Oct.  14,  1893.         *  "  Lancet,"  April  13,  1895. 


212  SURGERY    OF    THE    CHEST. 

There  is  reason  to  believe  that  an  empyema  of  the 
right  side  is  more  favourable  than  an  empyema  of  the 
left  side.  The  two  sides  are  about  equally  susceptible : 
of  Hofmokl's  60  cases,  26  were  right,  33  were  left,  and 
I  was  double  :  of  the  54  Great  Ormond  Street  cases, 
24  were  right,  28  left,  and  2  were  double.  It  seems 
natural  that  the  relation  of  the  heart  to  the  left  pleura 
should  make  a  left  empyema  more  hazardous  to  the 
patient,  and  more  embarrassing  to  the  surgeon,  than  a 
right  empyema.  Dr.  Marshall  observes  that  six  of  his 
seven  deaths  occurred  from  left  empyema.  '  This  is 
very  interesting,  and  confirms  the  belief  held  by  some 
that  left-sided  pleuro-pneumonia  is  always  more  dangerous 
to  life  than  when  it  occurs  on  the  right  side.'  And 
Hofmokl  says,  '  Left  effusions  need  more  care  in  punc- 
turing than  right  effusions,  partly  because  the  pericardium 
has  a  larger  share  in  the  affection  of  the  pleura,  and 
the  heart  is  more  exposed  to  pressure ;  partly  because 
there  is  greater  risk  of  the  great  vessels  being  stretched, 
or  even  twisted  or  compressed,  and  thus  giving  rise  to 
disturbance  of  the  circulation  and  respiration.  I  have 
often  noted  that  from  a  left  effusion,  even  a  very  large 
one,  you  cannot  draw  off  so  much  fluid  as  from  a  right 
one  of  the  same  size,  and  the  patient  is  more  likely,  as 
the  fluid  is  withdrawn,  to  get  attacks  of  faintness, 
dyspnoea,  restlessness,  and  dragging  pain  at  the  heart.' 

Simple  contusions  may  cause  pleural  effusions  which 
may  become  purulent  ;  but  there  are  only  one  or  two 
doubtful  cases  to  support  the  belief  that  any  such  eff"usion 
can  be  purulent  from  the  beginning.  Penetrating  wounds 
of  the  chest  may  lead  to  empyema  after  a  sero-fibrinous 
effusion,  or  the  blood  effused  into  the  pleura  may  break 
down,  and  empyema  may  thus  be  added  to  hsemothorax; 
but  acute  primary  suppuration  of  the  pleura  after  a  pene- 


EMPYEMA.  213 

trating  wound  is  very  rare,  and  even  if  it  does  occur, 
there  is  a  period  of  some  days  before  the  bruised  and 
bleeding  tissues  settle  down  to  suppurate.  The  best  way 
to  estimate  the  probability  of  empyema,  and  the  period 
of  its  onset,  after  a  penetrating  wound,  is  to  take  Schede's 
cases  (see  pages  2 1 4 — 2  21);  they  are  of  great  value  in 
teaching  the  behaviour  of  effusions  after  knife  or  bullet 
wounds,  their  uncertainty  and  complexity.  These  19 
cases  in  the  continuous  practice  of  one  surgeon  give 
the  whole  picture  of  the  chances  and  irregularities  of 
empyema  after  injury.  His  comment  on  them  is  as 
follows  : — '  In  penetrating  wounds  of  the  chest,  you  have 
to  deal  with  a  small,  insufficient  opening,  usually  ill-placed 
for  drainage,  and  with  an  effusion  which  is  hardly  ever 
pure  pus,  but  almost  always  foetid,  sero-purulent,  heemor- 
rhagic.  Out  of  my  19  cases,  5  suppurated;  3  out  of  11 
knife  wounds,  and  2  out  of  8  gunshot  wounds.  And 
of  all  nineteen,  only  one  died.'  We  cannot  too  carefully 
study  the  work  of  a  surgeon  whose  results  are  so  excellent. 
Or  the  wound  may  be  inflicted  during  a  deep  operation 
on  the  neck  or  on  the  axilla,  and  if  the  operation-wound 
be  or  become  infected,  the  pleura  may  suffer  with  it. 

A  man,'  aged  39,  had  a  large  lympho-sarcoma  of  the  right 
axilla,  and  during  operation  the  pleura  was  punctured. 
Fever,  exhaustion,  profuse  discharge  of  blood-stained  serum, 
and  emphysema  of  the  neck  and  chest  followed  the  operation, 
and  he  died  on  the  third  day.  Fos/  mor/efn,  the  axillary 
wound  contained  a  few  drachms  of  thin  pus,  and  was  covered 
with  a  layer  of  ashen  lymph.  The  pleura  was  punctured  in 
the  third  space,  and  was  all  covered  with  lymph,  and  con- 
tained two  or  three  ounces  of  blood-stained  fluid ;  so  did  the 
pericardium.  Cocci,  streptococci,  and  bacilli,  were  found  in 
the  axillary  wound,  and  vast  quantities  of  streptococci  in  the 
pleura. 

'  For  reference,  see  Lockwood,  on  "  Traumatic  Infection," 
1895,  p.  23. 


214 


SURGERY    OF    THE    CHEST. 


A  TABULAR    STATEMENT  OF  SCHEDE'S   CASES  OF  KNIFE 
ESPECIAL  REFERENCE  TO  THE  CHANCES 


No. 

Sex  AND 
Age. 

I 

M.38 

2 

M.28 

3 

M.23 

4 

F.   18 

5 

M.  22 

6 

M.  29 

7 

M.  26 

8 

M.  20 

Character  of  Whund. 


Stabbed  in  2nd  left 
space.  Hsemo- 
pneumothorax. 

Penetrating  stab,  left 
side  of  chest. 

Penetrating  wound 
in  the  back.  Em- 
physema and  pneu- 
mothorax. 

Several  knife-wounds 
left  side  of  chest. 
Hsemo- pneumo- 
thorax. 

Stabbed  in  4th  right 
space.  Haemo- 
thorax.  Dulness 
up  to  middle  of 
scapula. 

Large  punctured  and 
incised  wound  of 
back,  to  right  of 
spinous  processes 
of  5th  to  8th  dorsal 
vertebrae.  Hasmo- 
thorax. 

Stabbed  obliquely  in 
3rd  right  space, 
nipple  line.  Haemo- 
pneumothorax. 

Stabbed  in  3rd  left 
space,  nipple  line. 
Broad  wound,  ve- 
nous blood  flowing 
freely  from  it; 
patient  much  col- 
lapsed. Complete 
haemothorax. 


Treatment- 


Wound  simply 
disinfected  and 
sutured. 


Character  of 
Effusion. 


Wound  sutured ; 
no  drainage ;  ten 
days  later,  punc- 
ture. 


Aspiration  a  week 
after  injury. 


Exploratory  punc- 
ture, soon  after 
injury.  Wound 
disinfected  and 
drained. 

Wound  dilated ;  a 
large  vein  found 
wounded.  Disin- 
fection, plug- 
ging. Next  day, 
counter  -  opening 
8th  space. 


Blood  and  air. 


Altered  blood. 


Fluid  blood. 


Pure  blood. 


Pure  blood. 


EMPYEMA.  215 

WOUNDS  AND  BULLET  WOUNDS  OF  THE  CHEST:    WITH 
OF  INTRA-PLEURAL  SUPPURATION. 


Remarks. 


Complete  absorption  of  air  and 
blood.  Complete  recovery  in 
three  weeks. 

Discharged  in  nine  days. 


Wound   healed   in   twelve   days. 
Discharged  four  days  later. 


No  further  trouble.      Discharged 
in  a  month. 


Some  shrinking  of  the  effusion 
was  observed  a  few  days  after 
the  injury.  Recovered  in  a 
month. 


Complete  absorption.  Discharged 
about  a  month  after  injury. 


Drain  left  out  on  third  day.  Com- 
plete recovery  ;  discharged  in  a 
month. 


Drain  (which  had  been  passed 
right  through  from  wound  to 
counter-opening)  was  left  out  on 
twelfth  day.  Complete  recovery ; 
discharged  in  two  months. 


At  time  of  discharge,  there  was 
still  some  dulness  over  chest,  from 
spine  of  scapula  downward. 


The  puncture  let  out  7  oz.  blackish 
blood. 


No  evidence,  at  first,  that  pleura 
was  wounded.  Next  day,  dyspnoea. 
Dulness  reached  to  angle  of 
scapula.  15  oz.  fluid  blood  drawn 
off. 


Dulness  reached  to  angle  of  scapula; 
breath-sounds  lost ;  great  dyspna3a. 
Puncture  let  out  pure  blood. 


2l6 


SURGERY    OF    THE    CHEST. 
A  Tabular  Statement  of  Schede's  Cases  of  Knife 


No. 


Sex  and 
Age. 


M.  24 


M.  25 


M.  29 


M.36 


Character  of  Wound. 


A  fortnight  previous 
stabbed  in  2nd 
left  space,  close 
to  sternum.  Now, 
in  the  region  of  the 
scar,  a  pulsating 
swelling,  size  of 
hen's  egg;  and 
other  signs  of  left 
empyema. 


Contused,  lacerated 
wound  in  gth  right 
space,  anterior 
axillary  line,  freely 
admitting  finger 
into  pleura; 
pneumothorax  ; 
traumatic  emphy- 
sema. Later,  more 
than  one  circum- 
scribed empyema. 

Stabbed  through  2nd 
left  costal  cartilage, 
close  to  sternum. 
Patient  blanched  ; 
marked  dyspnoea. 

Shot  in  4th  left  space, 
nipple  line.  Bullet 
extracted  from 
back.  Hsemo- 
thorax  ;  signs  of 
pericardial  effusion. 


Treatment. 


Exploratory  punc- 
ture in  7th  space 
found  blood- 
stained pus.  In- 
cision of  pul- 
sating swelling 
let  out  gas,  and  a 
stream  of  dark 
blood.  Puncture 
in  8th  space  be- 
hind posterior 
axillary  line  let 
out  more  than  a 
pint  of  broken- 
down  foetid  blood. 
Irrigation.  Next 
day,  resection  of 
loth  rib,  posterior 
axillary  line. 

At  first,  simple  irri- 
gation and  drain- 
age of  wound. 
Three  weeks 
later,  resection  of 
5th  rib,  anterior 
axillary  line.  Six 
months  later,  re- 
section of  rib 
again. 


Counter-opening  in 
gth  space ;  drain- 
age right  through. 


Puncture  a  week 
after  injury  gave 
pure  blood, 
breaking  down. 


Charactfr  of 

Effusion. 


Resection  let  out 
large  quanti- 
ties of  very 
foetid,  dark 
flu  id,  with 
large  masses  of 
fibrin. 


At  first  opera- 
tion, puncture 
close  to  wound 
found  only 
frothy  blood, 
but  puncture 
of  4th  space 
found  thin, 
greenish  pus, 
about  ^  pint. 


3   oz.  blood   let 
out. 


Blood. 


EMPYEMA. 
Wounds  and  Bullet  Wounds  of  the  Chest — Continued. 


217 


Result. 


Remarks. 


Discharged  at  own  request,  three 
months  after  operation,  with  a 
fistula.  General  condition  very 
good  ;  lung  expanded ;  some 
deformity  of  chest  wall. 


Completely  healed  a  month  after 
second  operation ;  lung  well 
expanded. 


A  week  later,  he  had  delirium 
tremens,  and  died  suddenly, 
nine  days  after  the  operation. 


Recovery  ;  slight  dulness  ;  gene- 
ral condition  good. 


The  blood  flowed  so  freely  when  the 
swelling  was  incised,  that  the  sur- 
geon, thinking  a  large  vein  was 
opened,  plugged  the  incision,  and 
sutured  the  skin  over  it. 


Second  operation   found   two  large 
empyema  cavities,  with  viscid  pus. 


Post  mortem,  still  much  bloody  fluid 
in  pleura.  Pericardium  was  thick 
and  rough,  and  contained  a  quan- 
tity of  blood  clot.  Blood-stained 
serum  in  left  pleura. 

There  was  at  first  increase  of 
cardiac  dulness,  and  pericardial 
friction-sounds,  with  loss  of  heart- 
sounds.  Ten  days  after  injury, 
slight  haemoptysis. 


2l8 


SURGERY    OF    THE    CHEST. 
A  Tabular  Statement  of  Schede's  Cases  of  Knife 


No. 


Sex  AND 
Age. 


13 


15 


16 


M.  24 


M.  18 


F.  22 


M.27 


Character  of  Wound. 


Shot  in  5  th  left  space, 
between  paraster- 
nal line  and  nipple 
line.  Bullet  ex- 
tracted from  back. 
Some  bloody  sputa. 
Pulse  104,  fairly 
good.  A  week  later, 
pleuritic  effusion. 

Shot  in  4th  left  space, 
I  inch  from  edge  of 
sternum.  Very 
severe  haemorrh- 
age ;  patient  col- 
lapsed. Haemo- 
thorax,  with  pleural 
effusion. 

After  taking  strych- 
nine, shot  in  the  left 
breast  (5th  space). 
She  lived  through 
the  night  and  was 
then  brought  to  the 
Hospl.  Enormous 
hsemothorax ;  three 
days  after  injury, 
dulness  every- 
where, even  over 
apex  of  lung ;  heart 
far  displaced ;  pal- 
lor, feeble  pulse  ; 
intense  dyspnoea ; 
temperature  below 
normal. 

Shot  wounds  over  3rd 
and  5th  left  ribs, 
near  sternum.  One 
bullet  extracted 
from  back.  Hsemo- 
thorax, with  serous 
effusion. 


Treatment. 


Ice    bag 
heart. 


over   the 


A  week  after  injury, 
operation  was 
proposed,  but 
next  day  the  effu 
-■ —      began 


sion 
clear  up 


to 


Puncture  on  third 
day,  an  upper 
intercostal  space, 
gave  almost  pure 
blood.  No  oper- 
ation was  at- 
tempted, for  fear 
of  her  bleeding  to 
death. 


On  eighteenth  day 
after  inj  ury ,  punc- 
ture of  gth  space 
gave  I I  pints  of 
bloody  fluid. 
Puncture  was 
closed  with  a 
stitch. 


Character  of 

Effusion. 


Serous  pleurisy. 


Blood,  followed 
by  serous 
pleurisy. 


Enormous  quan- 
tity of  blood. 


Bloody  fluid. 


EMPYEMA. 
Wounds  and  Bullet  Wounds  of  the  Chest — Continued. 


219 


Result. 


Three  weeks  after  injury,  com- 
plete absorption  and  complete 
recovery. 


Complete  recovery  a  month  after 
injury. 


On  the  fourth  day  the  level  of 
effusion  began  slowly  to  sink. 
Complete  recovery  in  seven 
weeks. 


On  second  day  he  coughed  up  a 
small  mass  of  blood-clot,  mixed 
with  elastic  fibres.  Complete 
recovery  in  ten  weeks  :  perfect 
expansion  of  lung. 


Remarks. 


Day  after  injury,  excited  action  of 
the  heart,  cough,  haemoptysis  ; 
breathing  shallow. 


The  effusion,  a  week  after  injury, 
had  reached  as  high  as  the  spine 
of  the  scapula,  and  he  had  marked 
dyspnoea.  Next  day,  dyspnoea 
less;  effusion  stationary,  then  it 
began  to  be  absorbed. 


This  case  was  one  of  frightful 
gravity.  No  fracture  of  rib  could 
be  made  out ;  no  cough  or  expec- 
toration (it  is  therefore  possible 
that  the  enormous  haemorrhage 
came  from  an  intercostal  vessel, 
not  from  the  lung).  She  had 
spasms  from  the  strychnia  the  first 
night,  but  most  of  it  was  returned 
in  vomiting. 


No  immediate  signs  of  any  injury 
of  the  lung.  Effusion  only 
appeared  after  many  days.  Did 
not  re-collect  after  puncture. 


SURGERY    OF    THE    CHEST. 
A  Tabular  Statement  of  Schede's  Cases  of  Knife 


No. 


17 


iS 


SEX  AND 

Age. 


M.  24 


M.  23 


19 


M.  24 


Character  of  Wound. 


Five  months  ago, 
shot  close  to  right 
nipple ;  then  empy- 
ema ;  incision  8th 
space,  irrigation, 
and  drainage.  On 
leaving  out  drain, 
genl.  health  began 
to  fail,  and  empy- 
ema filled  again. 

Shot  himself  over  the 
heart,  splintering 
the  5th  rib,  and 
driving  it  into  the 
lung.  Severe 
haemorrhage,  then 
empyema ;  general 
condition  very  bad. 

Shot  himself  in  5th 
left  space,  just  over 
apex  of  heart. 
During  next  few 
days,  great  dys- 
pncea,  high  fever, 
intense  pain  and 
pleural  effusion. 
On  third  day,  dry 
tongue,  delirium  ; 
temperature  1043. 


Treatment. 


Incision  of  scar  of 
previous  opera- 
tion, irrigation, 
and  drainage. 


On  sixth  day,  resec- 
tion gth  rib,  pos- 
terior axillary 
line,  free  incision 
of  pleura,  double 
drain,  irrigation. 


Puncture  gave 
foetid,  bloody, 
sero-purulent 
fluid.  Resection 
loth  rib,  irriga- 
tion :  T  tube. 


Character  of 
Effusion. 


J  pints  of  pus 
let  out. 


FcEtid   pus   and 
blood-clots. 


Great  quantity 
of  dark,  foetid 
fluid,  with 
breaking-down 
blood-clots. 


Apart  from  injury,  it  is  doubtful  whether  there  is  any 
such  condition  as  true  primary  empyema,^  nor  does 
the  question  concern  surgeons.     As  to  the  usual  causes 

'  The  two  conditions  that  may  suggest  it  are  those  described 
by  Bouveret,  under  the  titles  of  "  Pleuresie  d'emblee  suppura- 
tive," and  "  Pleuresie  suraigue  de  Fraentzel,"  but  it  is  hardly 
possible  to  prove  that  these  cases  are  not  instances  of  very  acute 
sero-fibrinous  effusions,  so  rapidly  becoming  purulent  that  they 
appear  to  have  been  purulent  from  the  beginning. 


EMPYEMA. 
Wounds  and  Bullet  Wounds  of  the  Chest — Continued. 


Result. 


Remarks. 


Perfect  recovery  within  a  month ; 
almost  complete  expansion  of 
lung. 


Repeated  attacks  of  fever,  re- 
peated removals  of  fragments  of 
bone  or  of  clothing;  repeated 
blocking  of  the  drainage  by 
granulation  tissue.  Complete 
recovery  in  two  months. 


Rapid  recovery  in  fortnight,  with 
complete  expansion  of  lung. 
Drain  left  out  on  sixth  day. 


The  blocking  of  the  drainage  was 
obviated  by  using  a  T  tube, 
without  lateral  openings. 


There  was  every  reason  to  fear  the 
heart  had  been  injured,  but  no  sign 
of  it. 


of  empyema,  it  is  hard  to  estimate  their  frequency. 
Hofmokl's  60  cases  gives  37  of  empyema  after  pleuro- 
pneum.onia  or  sero-fibrinous  pleurisy,  without  any  signs 
of  phthisis  ;  12  of  empyema  of  tubercular  origin,  in- 
cluding I  of  empyema  from  tubercular  caries  of  a  rib; 
7  from  one  of  the  specific  fevers  (4  measles,  3  scarlet 
fever) ;  2  from  peritonitis  ;  and  i  each  from  penetrating 
wound,  gangrene  of  the  lung,  and  sarcoma  of  the  pleura. 


222  SURGERY    OF    THE    CHEST. 

Of  Konig's  76  cases,  61,  or  eighty  per  cent,  were  acute 
non-tuberculous  empyema;  and  it  has  been  said  that 
infection  by  the  pneumococcus  gives  twenty-five  per 
cent,  of  the  empyemata  of  adult  life,  and  fifty  per 
cent,  of  those  of  childhood.  As  to  the  relations  between 
tubercular  phthisis  and  pleural  effusions,  M.  Moutard- 
Martin  (1882)  found  only  7  cases  of  tubercular  disease 
in  84  cases  of  empyema  ;  and  M.  Leudet,  in  826  posf 
mortem  examinations  of  cases  of  phthisis,  found  pleural 
effusions  in  too  instances;  but  of  these  100  effusions, 
only  9  were  purulent ;  5  were  limited  to  a  part  of 
the  pleura,  4  occupied  the  whole  of  it.  The  effusion 
in  tubercular  phthisis  is  more  often  plastic  or  serous  than 
purulent ;  and  we  must  distinguish  empyema  due  to 
tubercular  phthisis  from  empyema  due  to  tubercular 
ulceration  of  the  pleura.  Finally,  as  to  the  conversion 
of  any  serous  effusion  into  an  empyema,  we  must 
remember  that  every  chronic  serous  effusion  tends  to 
become,  sooner  or  later,  purulent  :  in  162  cases  of 
'chronic  pleurisy'  the  effusion  was  purulent  in  loi.^ 

Empyema  Left  Without  Treatment. 
The  symptoms  and  physical  signs  of  empyema  in  its 
earlier  stages  do  not  belong  to  a  book  on  surgery ;  we 
may  therefore  leave  them,  and  consider  what  is  Hkely  to 
happen  to  a  patient  suffering  empyema,  if  his  disease  is 
left  to  itself.  We  are  bound  to  admit  the  possibility  of 
a  natural  cure  or  arrest  of  the  disease.  A  small  collec- 
tion of  pus  may  become  shut  off  by  adhesions,  and  may 
lie  for  years  in  a  capsule  of  very  thick,  tough,  fibrous 
tissue,  as  hard  as  cartilage,  till  it  becomes  dry  and  caked 
(see  Plate  V.,  Figs.  A  and  B) ;   such  cases  have  been 

'  Krause,  quoted  by  Bouveret,  loc.  cit.,  p.  378. 


c  S 
o  c 


.t;  o  E 

>       u 
™  S^   3 

O-g 

"■a  o 


«"«  G 


EMPYEMA.  223 

recorded  from  time  to  time,  mostly  in  children,  in 
empyema  after  j)neumonia ;  but  even  if  they  were  more 
numerous  than  they  are,  they  would  not  alter  the  duty 
of  the  surgeon  to  treat  all  cases  of  empyema  without 
delay.  Left  to  itself,  it  will  kill  the  patient  either  by 
compression  of  the  lung  and  heart,  pericarditis,  peritonitis, 
cerebral  abscess,  or  septicaemia  ;  or,  if  he  escape  death, 
he  has  again  to  face  the  danger  of  it  when  the  empyema 
breaks  through  the  pleura. 

The  pointing  of  an  empyema  beneath  the  skin,  the  old 
'  empyema  necessitatis,'  is  now  happily  not  often  seen.  I 
have  had  three  cases.  One  was  in  a  man  with  rapid 
tubercular  phthisis  ;  one,  in  a  boy,  had  been  diagnosed 
before  admission  to  Hospital  as  a  simple  abscess;  one,  in 
a  child,  had  been  allowed  to  burst  before  he  came  under 
my  care.  In  the  first  and  second  cases,  the  empyema, 
as  it  usually  does,  pointed  over  the  lower  ribs  about  the 
nipple-line :  in  the  child,  it  had  burst  about  the  second 
and  third  ribs,  near  the  sternum.  The  pointing  of  an 
empyema  outward  is  marked  by  pain,  tenderness,  and 
oedema  ;  and  oedema  is  often  present  over  an  empyema 
long  before  it  has  pointed  ;  but  we  must  not  take  an 
oedema  that  is  extended  far  over  the  chest  as  a  positive 
sign  that  an  effusion  is  purulent ;  a  serous  pleurisy  may 
cause  it.i  A  localised  patch  of  oedema  is  strong  evidence 
that  we  have  to  deal  with  an  empyema.  When  the 
empyema  has  pointed,  if  the  communication  between  the 
deep  and  the  subcutaneous  collections  of  pus  be  narrow 
or  sinuous,  the  subcutaneous  abscess  may  well  be  mis- 
taken, as  in  my  second  case,  for  a  '  simple  abscess  ' ;  even 
after  laying  it  open,  I  could  not  find  the  way  into  the 

'  Warburton  Begbie  (Syd.  Soc.  1S82)  gives  reference  to  four 
cases  of  firm  oedema  of  the  lower  limb  in  cases  of  serous  effusion 
into  the  pleura. 


224  SURGERY    OF    THE    CHEST. 

pleura,  and  had  to  go  on  with  the  ordinary  operation 
for  empyema.  But  if  the  communication  be  wide, 
the  superficial  abscess  may  transmit  the  movements  of 
respiration,  or  the  impulses  of  the  heart,  or  both.  In 
pulsating  pointing  empyema, i  the  cardiac  impulse  is 
synchronous  with  the  ventricular  systole ;  it  is  distinctly 
expansive  ;  the  effusion  is  always  on  the  left  side,  always 
large,  and  usually  chronic ;  the  heart  is  always  dis- 
placed, and  usually  fixed  in  its  displacement.  But  we 
must  note  that  an  effusion  may  pulsate  long  before  it 
points ;  there  is  an  intra-thoracic  pulsating  effusion,  as 
well  as  a  pointing,  pulsating  empyema ;  and,  in  two  or 
three  instances  of  intra-thoracic  pulsation,  the  effusion 
was  sero-fibrinous,  not  purulent ;  the  pulsating  effusions 
that  pointed  were,  of  course,  all  purulent — for  it  is  just 
the  purulent  softening  of  the  tissues  that  enables  an 
empyema  to  point.  M.  Comby  has  collected  27  cases 
of  pulsating  effusions  :  ten  or  twelve  of  these  were  intra- 
thoracic— all  on  the  left  side — the  rest  were  pointing 
empyemata.  In  the  intrathoracic  effusion,  the  pulsation 
is  usually  limited  over  two  or  three  spaces,  and  usually, 
but  not  always,  toward  the  front  of  the  chest;  but  Stokes 
had  a  case  of  a  huge  left  empyema,  with  great  displace- 
ment and  fixation  of  the  heart,  where  a  most  violent 
pulsation  was  observed  over  the  whole  side  of  the  chest, 
so  that  the  bed  was  shaken,  and  the  patient  disturbed 
from  sleep  by  it. 

As  regards  pulsating  pointing  empyema,  out  of  11 
cases  collected  by  Miiller,  10  were  on  the  left  side  (7 
single,  3  double),  and  i  was  on  the  right  side.     In  three 

'  The  whole  subject  of  pulsation  of  pleural  effusions  is  discussed 
at  great  length  by  Bouveret,  and  by  Comby,  "These  de  Paris," 
1881.  See  also  Wilson,  quoted  in  "  Wien.  Med.Wchnschr.,"  1S93, 
p.  476.  The  first  accounts  of  pulsating  empyema  we  owe  to  Irish 
physicians,  McDonnell  (1844),  Stokes  (1864),  and  Walshe  (1870). 


EMPYEMA.  225 

cases,  the  swelling  registered  not  only  the  movements  of 
the  heart,  but  also  those  of  respiration,  falling  in  inspira- 
tion, rising  in  expiration.  In  two,  the  tension  of  the 
swelling  varied  more  or  less  with  the  posture  of  the 
patient.  Its  pulsation  is  less  forcible  than  that  of  an 
aneurysm  in  the  same  position  would  be.  A  vascular 
malignant  growth  within  the  chest  may  pulsate ;  and  a 
rare  form  of  pneumonia  has  been  described,  with  pulsa- 
tion of  the  lung;  for  these  reasons  one  must  be  careful 
to  make  a  right  diagnosis.  For  the  explanation  of 
pulsation  in  a  pleural  effusion,  many  fanciful  reasons 
have  been  given — a  combination  of  pericarditis,  or  of 
pneumothorax,  with  the  effusion,  a  layer  of  collapsed 
lung  between  the  heart  and  the  effusion — but  it  is  still 
hard  to  see  why  some  effusions  should  pulsate,  and  not 
all. 

Pointing  empyema  will,  we  may  hope,  be  less  common 
now  than  it  was  in  former  years.  We  get  the  Hospital 
cases  at  an  earlier  stage,  and  we  operate  without  delay. 
In  1873-76,  out  of  12  cases  of  empyema  that  came  under 
the  care  of  Settegast,  6  had  already  been  suffered  to  burst 
outward  :  we  cannot  wonder  that  the  mortality  of  the  12 
cases  was  50  per  cent.  Out  of  Hofmokl's  60  cases,  the 
empyema  was  pointing  in  7,  but  had  not  yet  burst.  I 
have  had  three  pointing  empyemata — one  of  which  had 
burst ;  two  recovered,  in  the  third  the  empyema  healed, 
but  the  patient  died  of  acute  phthisis. 

Empyema  breaking  into  the  lung,  according  to 
Frantzel  (1875),  is  more  common  than  empyema 
breaking  outward  ;  and  Pel  (1890)  says  the  same.  Both 
these  disasters  will  become  less  common  in  proportion  as 
our  Hospital  patients,  or  their  parents,  become  less  neg- 
lectful of  the  early  stages  of  disease,  and  in  proportion 
as  the  early  diagnosis  and  treatment  of  empyema  become 

15 


226  SURGERY    OF    THE    CHEST. 

universal.  It  is  said  that  the  form  of  empyema  most 
likely  to  break  into  the  lung  is  a  small,  circumscribed 
effusion,  after  pneumonia,  in.  a  young  patient.  The 
method  of  invasion  of  the  lung  varies  from  a  very 
gradual  leakage  to  a  sudden  swamping  of  the  bronchi ; 
and  it  is  to  be  noted  that  the  passage  of  the  pus  into  the 
lung  is  not  likely  to  be  followed  by  the  passage  of  air 
from  the  lung  into  the  pleura ;  either  there  are  adhesions 
at  the  point  of  communication,  or  the  lung  tissue  is 
soaked  like  a  sponge  with  the  pus,  and  this  saturation  of 
the  patch  of  lung  round  the  opening  is  increased  by  the 
patient's  coughing,  so  that  the  small  bronchi  are  com- 
pressed. It  would  be  easy  to  quote  a  number  of  cases 
of  the  escape  of  an  empyema  into  the  lungs,  but  they 
differ  so  widely  in  their  clinical  features,  that  they  give 
no  rule  of  practice,  except  the  plain  warning  that  an 
earlier  operation  might  have  prevented  it  altogether. 
In  most  of  them,  the  patient  recovered.  Moore,  of 
Dubhn,!  even  records  two  cases  of  '  putrid  empyema,' 
where  recovery  thus  occurred.  In  other  cases,  the  lung 
was  invaded  even  after  operation. 

The  following  two  cases  offer  some  special  points  of 
interest : — 

1.  A  boy,  aged  9,  after  pneumonia,  was  found  to  have  a 
small  circumscribed  empyema  of  the  right  side.  On  aspira- 
tion, lour  ounces  of  healthy  pus  were  drawn  off;  but  on 
several  subsequent  occasions,  repeated  attempts  failed  to 
find  any  pus.  Between  eight  and  nine  weeks  after  admission 
to  Hospital,  he  was  seized  with  a  violent  fit  of  coughing,  and 
coughed  up  nearly  a  pint  of  pus,  followed,  a  few  hours  later, 
by  pus  mixed  with  mucus.     He  made  a  rapid  recovery. 

2.  A  man,  aged  64,  after  pneumonia,  showed  signs  of 
empyema,  and  on  aspiration,  thin,  blood-stained,  intensely 

1  Cases  of  Pleurisy  with  Foetid  Effusion,  simulating  Gangrene. 
"Dublin  Quarterly  Journal,"  xxxix.,  279.  But  it  is  not  im- 
probable that  these  were  cases  of  gangrene  of  the  lung. 


EMPYEMA.  227 

foetid  pus  was  drawn  off.  He  was  suffering  from  septic 
absorption — high  fever,  very  rapid  pulse,  dry  tongue — but  he 
resolutely  refused  operation.  A  few  days  later,  he  coughed 
up  a  great  quantity  of  pus,  and  finally  made  a  complete 
recovery. 

But  there  are  many  other  ways  along  which  an 
empyema  may  pass  beyond  its  natural  limits,  when  once 
it  has  escaped  from  the  pleura.  In  one  or  two  cases 
only  has  it  broken  into  the  oesophagus,  or  into  the  peri- 
cardium ;  and  it  very  seldom  breaks  through  the  more 
central  part  of  the  diaphragm.  More  often,  it  makes 
its  passage  past  the  attachments  or  the  crura  of  the 
diaphragm,  and  may  thus  point  in  the  lumbar  region,  the 
gluteal  region,  or  somewhere  in  the  anterior  abdominal 
wall ;  or  it  may  enter  the  sheath  of  the  psoas  muscle, 
and  follow  the  course  of  a  psoas  abscess.  These 
wanderings  of  empyema,  '  migratio7is  ifisoliies,'  are 
more  common  in  empyema  of  the  left  side,  and  in 
young  people ;  and  the  abscesses  that  they  cause 
may  move  with  respiration,  or  may  pulsate  with  the 
heart. 

I.  A  man,  aged  38,  was  under  my  care  some  years  ago, 
with  empyema  of  the  lower  portion  of  the  left  side,  after 
pneumonia.  At  the  first  operation,  no  pus  was  found,  but 
during  it  he  coughed  up  one  or  two  drachms  of  pus.  A  few 
days  later,  the  empyema  was  opened  and  drained.  He  did 
well,  and  three  weeks  after  the  operation  was  allowed  to 
leave  his  bed  :  that  same  day,  he  had  a  rise  of  temperature, 
and  after  this  he  was  feverish,  and  began  to  lose  ground. 
About  a  week  later,  he  began  to  complain  of  great  pain  down 
the  thigh,  and  kept  his  leg  drawn  up.  Four  days  later,  he 
also  had  pain  at  the  back  of  the  thigh,  below  the  gluteal 
muscles ;  there  was  diffuse,  tense,  painful  swelling  in  Scarpa's 
triangle,  and  an  incision  here,  about  an  inch  below  Poupart's 
ligament,  let  out  six  or  seven  ounces  of  pus.  I  found  a  huge 
abscess  cavity,  passing  up  out  of  reach  through  a  broad 
opening  beneath  Poupart's  ligament,  and  also  tracking 
round  the  inner  aspect  of  the  femur  to  the  back  of  the  thigh, 


228  SURGERY    OF    THE    CHEST. 

rendering  necessary  a  counter-opening.     He  made  a  com- 
plete recovery. 

2.  A  girl,  aged  14,  with  scars  of  tubercular  caries,  was 
admitted  to  Hospital  (1877)  with  a  left  pleural  effusion,  which 
was  allowed  to  go  for  many  weeks  without  active  treatment. 
Eight  weeks  after  admission,  she  complained  of  pain  about 
the  left  hip  joint,  and  here  a  huge  abscess  was  found,  six 
inches  by  nine,  occupying  the  upper  part  of  the  ilium  and 
the  gluteal  region.  It  was  punctured,  and  several  ounces  of 
pus  were  let  out ;  it  was  now  observed  that  the  breath-sounds 
were  more  clearly  heard  over  the  affected  side.  Two  days 
later,  it  was  again  punctured,  and  thirteen  ounces  of  pus  were 
let  out.  '  The  percussion  note  returned  over  the  chest,  the 
breath-sounds  were  heard  everywhere,  the  segophony  dis- 
appeared.' The  child  was  taken  away  from  hospital,  and  the 
end  of  the  case  is  not  known. 

3.  A  woman,  aged  40,  suffering  with  tubercular  phthisis, 
and  with  effusion  of  pus  and  of  air  (pyo-pneumothorax)  in 
the  right  pleura,  had  in  the  right  lumbar  region  a  fluctuating 
reducible  swelling.  It  refilled  after  puncture  and  evacuation, 
and  plainly  contained  both  air  and  fluid.  Nothing  more  was 
done  on  account  of  the  state  of  her  lungs,  and  she  died  a  few 
weeks  later.  Posi  mortem,  the  pleura  was  found  emptied  of 
effusion,  the  lung  was  collapsed  to  a  mere  remnant  ;  a 
fistulous  track,  burrowing  among  the  muscles  in  the  loin, 
united  the  cavity  in  the  loin  with  the  lowest  level  of  the 
pleura. 

4.  A  woman,  aged  22,  five  days  after  confinement,  had 
acute  pleurisy  of  the  left  side,  with  rapid  effusion.  In  a  week 
the  effusion  had  sunk  to  one-half  of  its  former  level  ;  at  the 
same  time,  in  that  side  of  the  abdomen,  there  appeared  a 
large,  firm,  rounded,  tender  swelling,  overlying  the  kidney, 
limited  below  by  the  sigmoid  flexure  pushed  downward  and 
inward,  and  filling  nearly  the  whole  of  the  left  side  of  the 
abdomen  :  its  area  of  dulness  was  continuous  with  that  of 
the  spleen.  Pus  was  drawn  off  from  it  by  an  exploratory 
puncture  :  not  offensive,  containing  no  renal  epithelium  or 
casts,  a  few  staphylococci,  no  tubercle  bacilli,  and  yielding 
an  abundance  of  crystals  of  tyrosin  when  it  was  dried.  The 
swelling  was  incised,  and  about  a  pint  and  a  half  of  pus  was 
let  out.  Next  day,  there  was  also  a  free  evacuation  of  pus 
per  rectum.     The  patient  did  well. 

These  four  cases  may  serve  to  show  some  of  the 
courses  and  characters  of  migrating   empyema.     Many 


EMPYEMA.  229 

Others,  and  full  consideration  of  each  group  of  them,  will 
be  found  in  Bouveret's  great  work  on  empyema. 

I  have  in  this  chapter  taken  only  a  few  of  the  many 
questions  that  centre  round  empyema;  questions  of 
diagnosis  have  been  left  untouched,  and  many  other 
matters  regarding  it.  I  have  attempted  only  to  note 
some  few  facts  that  are  rather  surgical  than  medical,  and 
concerned  less  with  diagnosis  than  with  operation. 


230 


CHAPTER  XVI. 

THE  OPERATION  FOR  EMPYEMA. 

The  treatment  of  empyema  is  a  very  wide  subject,  and 
there  are  three  conditions  attached  to  it.  The  cavity 
must  be  thoroughly  emptied  and  drained;  the  pleura 
must  be  protected  from  further  infection  ;  and  the  lung 
must  be  left  free  to  expand.  The  old  routine  treatment 
by  repeated  punctures  or  aspirations  has,  happily,  gone 
for  ever.  As  a  general  method,  it  was  full  of  faults  ; 
but  here  and  there,  by  a  sort  of  chance,  it  was  successful. 
It  might  cure  a  small  recent  circumscribed  post-pneu- 
monic empyema  in  a  child,  a  thin-walled  cavity  contain- 
ing a  few  ounces  of  pus,  behind  ribs  not  yet  rigid ;  such 
cases  did  happen  now  and  again.  It  had,  and  still  has, 
a  narrow  field  of  usefulness,  in  some  cases  of  advanced 
phthisis,  or  pyaemia,  or  in  very  old  and  enfeebled  patients, 
or  in  malignant  disease,  as  a  temporary  or  palliative 
measure  :  and  that  is  the  most  that  can  be  said  for  it. 

Nor  need  we  consider  the  early  attempts  to  combine 
drainage  and  irrigation  with  puncture ;  there  was  no 
efficiency  in  the  combination  of  three  inefficient  methods; 
one  cannot  irrigate  the  pleura  through  an  aspirating- 
needle,  or  drain  it  with  a  narrow  tube  passed  down  the 
cannula  of  the  trochar  after  puncture  ;  the  lotion  stays 
in,  the  pus  does  not  come  out,  the  tube  gets  blocked,  a 
fresh  puncture  is  made,  also  in  vain,  and  so  the  whole 
thing  fails.  But  one  method  must  be  mentioned  here, 
not  because  it  is  in  itself  very  valuable,  but  because 
the  controversy  raised  about  it  in  Germany  illustrates 


OPERATION    FOR    EMPYEMA.  231 

the  whole  subject  of  the  treatment  of  empyema:  and  that 
is  Bulau's  permanent  syphon-drainage  by  means  of  a 
long  rubber  tube  having  one  end  in  the  empyema,  and 
the  other,  at  a  lower  level,  in  some  antiseptic  solution. 
The  especial  claim  made  on  its  behalf  is  that  it  alone  ot 
all  methods  both  keeps  out  the  air,  and  also  tends 
directly  to  promote  expansion  of  the  lung  by  a  steady 
process  of  suction.  I  have  put  in  an  Appendix  Dr. 
Bulau's  account  of  this  method,  and  added,  in  the  form 
of  a  debate,  what  has  been  said  for  and  against  it  by 
other  surgeons.  But  whoever  will  read  it  carefully  will 
agree  with  the  majority,  that  it  is  to  be  kept  for  excep- 
tional cases,  and  is  tedious,  uncertain,  incomplete,  and 
not  wholly  free  from  danger.  We  need  not  consider  the 
methods  which,  more  or  less,  resemble  it,  but  may  go  on 
to  the  present  operation  for  empyema. 

(i,)  The  Exploratory  Puncture. — -As  one  should 
always  sound  a  patient  with  stone  in  the  bladder 
immediately  before  operation,  so  one  should  make  an 
exploratory  puncture  immediately  before  operation  on 
an  empyema  ;  and  not  omit  this  safeguard  because  pus 
was  found  on  puncture  a  day  or  two  previously.  One 
must  use  a  proper  exploring  syringe,  with  a  long  steel 
needle ;  the  old  '  grooved  needle,'  though  its  evil  habit 
of  leaving  a  drop  of  pus  behind  it  can  do  no  harm  when 
a  free  incision  is  at  once  made  along  the  track  of  it,i  is 
an  instrument  that  should  be  allowed  to  remain  in 
oblivion  •  it  has  done  great  harm,  and  has  fallen  into  dis- 
use altogether.    Even  with  the  exploring  syringe,  puncture 

* '  I  have  frequently  seen  simple  puncture  of  an  empyema 
followed  by  phlegmonous  inflammation  along  the  track  of  the 
needle,  even  though  every  precaution  was  taken  in  the  use  of 
antiseptics  ;  and  more  than  once,  in  cases  of  tuberculous  patients 
with  foetid  pyo-pneumothorax,  I  have  seen  puncture  followed  by 
extensive  foetid  abscess,  with  gangrene  of  the  skin.'  —Ho/tnokl. 


232  SURGERY    OF    THE    CHEST. 

through  a  thick  layer  of  muscle  should,  if  possible,  be 
avoided  ;  in  one  of  my  cases,  where  the  signs  of  effusion 
were  most  marked  over  the  front  of  the  chest,  puncture 
with  an  exploring  needle  through  the  pectoral  muscle 
was  followed  by  a  small  abscess  beneath  it.  Of  course, 
the  skin  must  be  carefully  cleansed  before  puncture,  and 
either  ethyl-chloride  or  cocain  should  be  used ;  either 
a  strong  solution  of  cocain,  20  per  cent.,  painted  on 
the  skin,  or  a  weak  one,  2^  per  cent.,  injected  under 
it ;  or,  better  still,  first  paint  the  skin,  then  put  the 
cocain  under  it.  The  needle  of  the  syringe  should 
be  steadied  and  guarded  so  as  not  to  go  too  far,  and 
should  not  be  thrust  forward  with  a  jerk,  but  guided 
over  the  upper  edge  of  the  rib.  Before  withdrawing  it, 
one  must  be  careful  to  leave  off  drawing  on  the  piston. 
And  even  if  one  fails  to  find  fluid,  there  may  be  a  minute 
drop  of  it  in  the  needle,  enough  for  the  microscope. 
In  a  case  of  malignant  disease  of  the  lung  simulating 
pleural  effusion,  one  may  find  a  shred  of  the  growth  in 
the  needle.  The  contents  of  the  needle,  therefore,  must 
be  carefully  examined  with  the  microscope,  even  if  it 
be  only  the  smallest  drop  of  fluid  or  shred  of  tissue. 

(2,)  The  Ancesthetic,  and  the  Position  of  the  Patient. — 
In  dealing  with  a  large  empyema,  it  is  very  important — 
especially  if  it  be  on  the  left  side  —not  to  turn  the  patient 
far  over  on  to  the  sound  side,  lest  the  action  of  the  sound 
lung,  or  of  the  heart,  should  be  affected.  Some  years 
ago,  a  boy,  aged  10,  was  admitted  to  Hospital  with 
total  empyema  of  the  left  side,  distension  of  the  inter- 
costal spaces,  displacement  of  the  heart,  and  general 
condition  very  serious.  He  was  at  once  taken  to  the 
theatre,  and  chloroform  was  very  carefully  administered. 
He  was  turned  a  little  way  over  on  to  his  other  side, 
without   any   harm    resulting;    then,   after   waiting  and 


OPERATION    FOR    EMPYEMA.  233 

watching  him,  I  turned  him  over  a  little  further,  and 
made  my  incision.  At  this  moment,  he  stopped  breath- 
ing, but  his  pulse  went  on,  and  the  anaesthetist  did  not 
at  once  notify  the  cessation  of  the  breathing.  Then  the 
pulse  stopped,  and  neither  by  letting  out  the  pus,  nor 
by  artificial  respirationj  were  we  able  to  restore  life.  The 
giving  of  an  anaesthetic  we  can  hardly  avoid ;  but  we 
must  not  keep  the  patient  without  food  for  many  hours 
before  the  operation,  and  we  may  do  well  to  give  him 
some  brandy  immediately  before  it.  I  believe  that  with 
these  precautions,  and  with  the  patient  not  turned  far 
over,  the  anaesthetic  itself  is  free  from  any  special  risk ; 
and  of  all  the  cases  collected  by  Mr.  Pitts,  only  one  died 
during  the  operation. 

3.  Incision  and  Resection. — If  the  effusion  be  complete 
and  not  limited  by  adhesions,  the  incision  should  be 
made  over  the  eighth  space,  or  the  ninth  rib,  just  out- 
side the  angle  of  the  scapula^  If  it  be  small,  partial, 
circumscribed,  the  operation  must  follow  the  guidance  of 
the  exploring  syringe.  It  is  of  great  importance  that  the 
incision  should  be  free,  and  that  every  layer  should  be 
cleanly  and  thoroughly  divided,  so  that  a  good  inch  of 
rib  is  clearly  exposed.  There  is  no  need  to  be  careful  to 
keep  the  periosteum  of  the  rib,  indeed  'subperiosteal 
resection  '  is  a  mistake  ;  one  has  only  to  free  the  rib  all 


'  'In  a  complete  empyema,  no  position  is  better — none,  indeed, 
is  so  good — as  that  opposite  the  ninth  rib,  just  outside  the  angle 
of  the  scapula,  (i,)  It  is  just  above  the  level  to  which  the  dia- 
phragm becomes  adherent  to  the  ribs  when  it  has  been  drawn  up 
as  much  as  possible  ;  (2,)  It  is,  therefore,  very  soon,  if  not  at 
first,  one  of  the  most  dependent  parts  of  the  pleural  cavity  when 
the  patient  is  standing  up,  and  it  is  always  the  most  dependent 
part  when  he  is  lying  on  his  back ;  (3,)  I  practically  find  that 
this  is  a  much  more  advantageous  position.'  Godlee,  Brit. 
Med.  Ass.  Meeting  at  Nottingham.  "  Brit.  Med.  Journ.,"  1892, 
ii..  828. 


234  SURGERY    OF    THE    CHEST. 

round,  isolate  it,  and  divide  it  with  very  large  strong 
forceps  ;  but  one  may  first  groove  it  with  a  saw,  if  it  be 
so  thick  that  the  forceps  alone  might  splinter  it.  The 
Hippocratic  method  of  trephining  the  rib,  so  as  to  avoid 
the  intercostal  vessels,  has  lately  been  revived  by  Rey  in 
Italy^ ;  but  it  is  wholly  unsuited  for  the  treatment  of 
empyema. 

Incision  without  resection  is,  at  present,  out  of  favour, 
and  the  removal  of  an  inch  of  rib  has  come  to  be  almost 
an  integral  part  of  the  operation.  Yet  Rosenbach^  has 
lately  recorded  a  series  of  1 5  cases  of  empyema,  of  all 
kinds,  and  in  patients  of  all  ages,  treated  by  incision 
without  resection,  every  one  of  them  successful;  and  it 
is  quite  possible  that  this  method  may  be  again  revived. 
Foltanek  advocates  it  for  empyema  in  childhood,  as 
giving  a  smaller  wound  and  an  easier  operation.  Of 
Hofmokl's  60  cases,  18  were  thus  treated.  I  have  done 
it  several  times,  and  it  has  always  answered  well ;  in  one 
case,  105  ounces  of  pus,  with  fibrin,  were  let  out,  and 
the  patient  recovered  very  quickly.  It  is  true  that  the 
reasons  brought  against  resection  are  of  very  small  value, 
and  it  gives  the  surgeon  command  over  masses  of  fibrin, 
which  are  often  present  in  cases  of  complete  empyema 
of  some  weeks'  duration  (see  Schede's  cases),"'  and  it 
ensures  ample  room  for  drainage  :  still,  there  are  cases 
where  it  is  not  necessary.  We  must  take  each  case  on 
its  own  merits  ;  in  most,  we  do  well  to  resect ;  but  it 
is  not  an  essential  part  of  the  operation,  and  cases  do, 
from  time  to  time,  occur  where  the  surgeon  had  best 
content   himself  with   a   free  incision,    properly   placed 


'See  "Brit.  Med.  Journ.,"  Sept.  21,  1895,  and  a  case  recorded 
by  Surgeon-Captain  Moffet,  March  7,  1896. 
*  "  Wien.  Med.  Presse,"  1892,  p.  515. 
3  See  also  Glaser  (Appendix  B). 


OPERATION    FOR    EMPYEMA.  235 

and  made,  without  resection.  There  are  signs  that  the 
surgery  of  the  chest  is  beginning  to  draw  back  a  Httle 
over  one  or  two  operations — if  such  a  phrase  may  be 
pardoned  ;  and  it  is  not  improbable  that  in  a  few  years 
we  shall  define,  more  accurately  than  now,  those  cases 
where  resection  is  or  is  not  necessary. 

4.  Evacuation  of  the  Empyema.- — -Since  the  pleura 
may  be  greatly  thickened,  it  must  be  opened  with  the 
point  of  the  knife  rather  than  with  a  director.  Either  the 
intercostal  vessels  are  obliterated,  or  one  avoids  them 
by  noting  the  impress  of  the  resected  rib  on  the  pleura  ; 
anyhow,  they  do  not  offer  any  trouble  during  the  opera- 
tion. And  the  rule  is  as  old  as  Hippocrates  that  the 
effusion  must  not  be  let  out  too  rapidly,  lest  the  patient 
should  faint. 

Two  or  three  minor  questions  have  to  be  considered. 
Ought  the  surgeon  to  explore  the  cavity  with  his  finger, 
or  to  curette  its  walls,  or  to  irrigate  it  ?  I  have  never 
learned  much  from  exploring  the  cavity  with  my  finger.^ 
Bouveret  advocates  it  for  three  reasons ;  you  can 
ascertain  the  exact  extent  of  the  cavity,  remove  masses 
of  fibrin,  and  break  down  the  false  membranes  which 
sometimes  are  found  dividing  up  an  empyema  into  a 
system  of  abscesses  {empyeme  cloisonne).  But  the  exact 
extent  of  the  empyema  is  not  of  much  practical  concern; 
the  masses  of  fibrin  will  find  their  way  out  of  the  cavity 
without  the  surgeon's  help ;  and  the  plan  of  breaking 
down  adhesions  of  which  one  knows  very  little,  and  sees 
nothing,    seems  to   me   best  avoided.      And  as  regards 

'  A  case  showing  the  advantage  of  exploring  the  cavity  with 
the  finger  is  given  in  the  chapter  on  Pericardial  Effusions. 
Empyema  and  purulent  pericarditis  were  both  present  together ; 
and  the  surgeon,  having  opened  the  empyema,  felt  with  his  finger 
the  distended  pericardium,  and  opened  it  and  drained  it  through 
the  incision  in  the  chest- wall. 


236  SURGERY    OF    THE    CHEST 

interfering  with  the  walls  of  the  cavity,  here  again  we  may 
fall  into  the  fault  of  officious  surgery.  '  I  always  wash  the 
cavity  out  at  once,' says  Schede,  'and  if  that  does  not 
seem  to  be  satisfactory,  I  rub  its  walls,  and  give  them  a 
good  scraping  with  a  Volckmann's  spoon.  It  is  very  im- 
portant to  get  the  cavity  disinfected  once  and  for  all,  and 
I  abhor  subsequent  irrigation.'  But  to  scrape  an  ordinary 
empyema  seems  to  me  wholly  unnecessary  and  undesir- 
able. As  regards  irrigation  at  the  time  of  operation 
(irrigation  during  after-treatment  is  considered  in  the 
next  chapter),  there  are  different  opinions,  some  in 
favour,  others  against  it.  I  believe  one  should  avoid  it, 
because  the  patient,  being  under  the  anaesthetic,  cannot 
show,  by  coughing  or  by  complaining  of  pain,  that  the 
irrigation  ought  at  once  to  be  stopped.  1  have  given  it 
up  in  ordinary  cases  ;  and  I  wholly  disagree  with  the 
routine  treatment  that  Dr.  White  and  Dr.  Wood^  advise — 
'  It  has  been  our  practice  to  irrigate  the  pleura  until  the 
fluid  came  away  clear ;  no  harm  has  seemed  to  us  to 
follow  this  procedure.' 

5.  Drai7iage,  Dressing,  and  Posture  in  Bed. — The 
perfect  tube  has  at  last  been  evolved  from  the  innumerable 
varieties  that  have  been  used  for  empyema.  Metal  tubes 
might,  and  sometimes  did,  cause  caries  of  a  rib,  or 
secondary  hsemorrhage  from  an  intercostal  vessel.  Long 
tubes  might,  and  sometimes  did,  irritate  the  diaphragm, 
or  get  caught  in  adhesions,  or  kinked  ;  all  complicated 
arrangements — two  tubes,  side  by  side,  or  one  inside  the 
other,  or  a  whole  row  of  tubes  like  a  Pan's  pipe,  or  a  tube 
brought  out  through  a  counter-opening — these  also  were 
bad.  The  perfect  tube  is  a  single,  short,  large,  flanged 
rubber  tube,  without  side  holes,  with  a  bore  of  f  to  f  inch, 

'  The  Treatment  of  Empyema,  with  Selected  Cases,  Detroit, 
1804. 


OPERATION    FOR    EMPYEMA.  237 

long  enough  to  reach  the  cavity,  without  projecting 
far  into  it.  The  danger  that  a  tube  may  shp  or  be 
drawn  into  the  pleural  cavity,  will  be  considered  in  the 
next  chapter;  so  will  Wagner's  method  of  loosely  packing 
the  cavity  with  gauze,  in  cases  where  drainage  has  failed. 

The  dressing  is  not  the  least  important  part  of  the 
operation.  It  must  be  of  sufficient  extent  and  thickness, 
soft,  carefully  fitted,  covering  the  whole  chest,  including 
the  arm  on  the  affected  side  down  to  the  elbow,  accu- 
rately adjusted  to  the  skin  round  its  whole  area.  In 
the  operation  for  empyema,  there  are  at  least  three 
things  the  dressing  must  do.  It  must  preserve  the  cavity 
from  further  infection ;  it  must  receive  and  distribute 
through  itself  a  discharge  which  is  sure  to  be  profuse, 
and  may  come  in  a  rush  some  hours  after  the  operation ; 
and  it  must  act,  to  some  extent,  as  a  valve,  so  that  the 
patient  may  rid  himself  by  coughing  of  the  air  that 
has  filled  the  cavity,  without  taking  in  a  fresh  supply  at 
every  inspiration. 

The  posture  of  the  patient  in  bed  after  the  operation 
is  also  important.  I  have  given  several  cases  of  effusion 
of  blood  into  the  pleura  which  could  be  emptied  out  of 
the  patient's  chest,  almost  as  one  pours  water  out  of  a 
jug,  by  placing  him  in  some  special  position  :  the 
same  thing  has  been  noted  in  a  few  cases  of  empyema  ; 
but  chiefly,  I  think,  in  cases  after  gun-shot  wound. 
Konig  has  a  regular  system  of  attitudes ;  for  the  first 
few  days  he  keeps  the  patient  on  his  side,  turning  him 
occasionally  a  little  backward  or  forward.  Then,  he  has 
him  raised  by  an  assistant  four  times  daily,  who  lifts  him 
by  the  pelvis,  while  the  patient  lies  on  the  shoulder  of 
the  affected  side;  and  in  this  position  he  is  turned  to  and 
fro,  so  as  to  empty  his  chest  as  much  as  possible.  Later, 
it  will  suffice  if  he  puts  his  body  over  the  side  of  the 


238 


SURGERY    OF    THE    CHEST. 


bed,  and  supports  himself  with  his  outstretched  hand  on 
the  floor.  But  to  justify  these  gymnastics,  we  must  note 
that  Konig  makes  his  incision  higher  than  most  surgeons, 
at  the  level  of  the  fourth,  fifth,  or  sixth  rib.  They  belong, 
so  far  as  they  are  at  all  valuable,  to  the  after-treatment, 
not  to  the  present  chapter.  But  certainly  one  must  be 
careful  that  the  patient  is  put  back  to  bed  in  a  good 
position  for  drainage,  and  not  by  any  neglect  allowed  to 
lie  on  his  sound  side. 

To  illustrate  the  whole  course  of  empyema,  and  its 
treatment,  I  give  Schede's  cases,  arranged  in  a  table 
showing  clearly  those  aspects  of  the  disease  and  of  the 
operation  that  are  of  most  practical  importance.  It  will 
be  noted  that  on  three  occasions  an  operation  of  very 
great  severity  was  practised  ;  but  I  include  these  cases 
with  the  rest,  on  account  of  their  general  character  ;  and 

SCHEDE'S     CASES     OF     OPERATION 


No. 


Sex  and 
Age.    I 


Character  of  Disease. 


M. 


M. 


M.  26 


M.2i 


Acute  left  empyema, 
of  enormous  size. 


Acute  right  empye- 
ma, after  pneumo- 
nia ;  dulness  up  to 
fourth  rib. 

Acute  left  empyema, 
after  pneumonia ; 
dulness  up  to  spine 
of  scapula.     T.  103. 

Acute  empyema, 
whole  left  side  of 
chest,  after  scarlet 
fever. 


Operation. 


Resection  of  tenth 
rib  in  posterior 
axillary  line. 

Incision  of  sixth 
space  in  posterior 
axillary  line. 

Resection  of  ninth 
rib. 


Resection  of  eighth 
rib. 


Fluid  Let  Out. 


Nearly  a  quart 
of  pus,  with 
thick  masses  of 
fibrin. 

Character  of  pus 
not  stated. 


Large  quantity 
of  pus,  with 
thick  masses 
of  fibrin. 

Thick  pus,  with 
flocculent 
shreds  of  fibrin. 


OPERATION    FOR    EMPYEMA. 


239 


will  give,  in  the  chapter  on  Chronic  Empyema,  examples 
of  that  'thorax  resection'  which  we  especially  associate 
with  Schede.  The  notes  of  many  of  my  own  cases  are 
so  defective  that  I  am  compelled,  for  the  sake  of  making 
this  book  as  useful  as  possible,  to  give  only  such  among 
them  as  may  serve  here  and  there  to  illustrate  points  of 
special  interest. 

Cases  of  double  empyema  must  be  treated  by  the 
rules  already  given  :  except  for  such  preliminary  aspir- 
ation as  may  enable  the  patient  to  avoid  the  shock  of 
the  two  operations,  which  must  not  be  done  on  the 
same  day.  A  good  instance  of  this  condition,  with  many 
references,  is  given  by  Dr.  Coupland  and  Mr.  Pearce 
Gould,  in  the  '  Transactions  of  the  Clinical  Society,'  for 
l8qi. 


FOR    EMPYEMA     (up   to    1890). 


Result. 


Remarks. 


Complete  recovery    in    nineteen 
days. 


Operation,   June  4th.     Complete 
recovery  end  of  August. 


Complete  recovery  in  six  weeks. 


Complete  recovery  in  ten  weeks. 


Lung  fully  expanded  by  fourth  day. 
Tube  left  out  on  tenth  day. 


Drained  for  many  weeks.  Had,  at 
same  time,  an  abscess  in  the  left 
thigh. 

Had  been  punctured  a  fortnight 
previously. 


Lung  expanded,  but  breath-sounds 
weak.     Slight  lateral  curvature. 


240 


SURGERY    OF    THE    CHEST. 

Schede's  Cases  of  Operation  for 


No. 

Sex  AND 
Age. 

Character  of  Disease. 

Opkration. 

Fluid  Let  Out. 

5 

M.  18 

Circumscribed  bi-lo- 

Resection  of  ninth 

No    mention  of 

cular  left  empyema, 

rib:     later,   of 

masses       of 

with  pneumonia. 

seventh       and 
eighth,    with    re- 
section of  fourth 
rib    for     counter 
opening. 

fibrin. 

6 

F.  29 

After  pleurisy,  gan- 

Resection of  eighth 

Pus  on  right  side 

grene  of  right  lung, 

right  rib, posterior 

foetid. 

with      total      pyo- 

axillary    line. 

pneumothorax. 

Later,       syphon- 

Later,     simple 

drainage    of    left 

circumscribed    left 

empyema. 

empyema. 

7 

M.28 

After       pneumonia, 

Free  resection    of 

Nearly   a  quart 

gangrene    of  right 

ninth   and    tenth 

of      greyish 

lung,     with     enor- 

ribs,   two     large 

black,  intense- 

mous    putrid    em- 

drainage tubes. 

ly    foetid    pus, 

pyema,  which  burst 

with      large 

into  a  bronchus. 

pieces  of  gan- 

grenous   lung- 

tissue. 

8 

F.35 

After        pneumonia. 

Lumbar  abscess  in- 

Character of  pus 

right  empyema. 

cised.     Later,  re- 

not stated. 

which  burrowed  in- 

section of  eleventh 

to  right  lumbar  re- 

rib. 

gion. 

9 

M.  24 

After        pneumonia, 

Resection  of  sixth 

Character  of  pus 

right  empyema. 

rib,    posterior 
axillary     line. 

not  stated. 

,  1 

Later,    a     fistula 

remained,    which 

1 
1 

was  irrigated. 

10 

F.  20 

After   pneumonia  of 

Resection       tenth 

A  large  quantity 

left  lower  lobe,  cir- 

rib,   posterior 

of  foetid    pus. 

cumscribed  left 

axillary  line. 

with      large 

empyema. 

masses  of 
fibrin. 

11 

M.  31 

Empyema. 

Resection        ninth 
and  tenth  ribs  in 
posterior  axillary 
line. 

Large  quantity 
of  very  foetid 
pus. 

OPERATION    FOR    EMPYEMA. 
Empyema  (up  to   iSqo) -Continued. 


241 


Result. 


Complete  recovery  in  ten  weeks. 


Complete  recovery.  Right  side 
healed  in  two  months,  left  side 
in  three  days. 


Complete      recovery, 
healed  in  two  months. 


Wound 


Death  three  weeks  after  opera- 
tion, from  extensive  ulceration 
of  the  colon. 


Death  three  and  a  half  months 
after  operation,  from  multiple 
cerebral  and  cerebellar  ab- 
scesses. 


Death  within  a  fortnight,  from 
multiple  abscesses  of  right 
frontal  and  temporo-sphenoidal 
lobes. 

On  third  and  fourth  days  after 
operation,  profuse  haemor- 
rhages from  the  cavity. 


Remarks. 


Had  been  previously  incised  in  sixth 
space,  anterior  axillary  line,  and 
drained. 


A  piece  of  gangrenous  right  lung 
was  coughed  up.  Fluid  syringed 
into  right  cavity  came  through 
mouth. 


Before  operation,  he  used  to  cough 
two  to  four  pints  daily ^of  foetid  pus. 
Repeated  exploratory  punctures 
before  operation  had  failed  to  find 
pus :  probably  cannula  was  not  long 
enough,  as  he  was  extraordinarily 
muscular. 

Lung  failed  to  expand,  and  was 
found  post  motem  packed  against 
the  spine. 


Injection  of  the  fistula  caused  intense 
collapse,  and  was  not  repeated. 
Post  mortem,  tuberculous  caseous 
foci  in  left  upper  lobe  :  pericardial 
adhesions. 

Ulceration  of  the  lower  bowel.  Puru- 
lent peritonitis,  with  effusion  into 
Douglas's  pouch. 


Death  on  fifth  day.  Pest  mortem, 
several  abscesses  in  the  lung. 
Source  of  haemorrhages  not  dis- 
covered. 

16 


242 


SURGERY    OF    THE    CHEST. 

Schede's  Cases  of  Operation  for 


No. 


Sex  AND 
Age. 


13 


14 


15 


16 


17 


18 


M.35 


F.38 


M.  3 


M.23 


M.  63 


Character  of  Disease. 


M.33 


M.28 


After  pneumonia  of 
right  lung,  gan- 
grene with  pyo- 
pneumothorax. 

Small  circumscribed 
empyema,  with  fis- 
tulous opening. 

Fistula  in  third  right 
intercostal  space, 
large  right  empye- 
ma, chronic. 

Four  years  ago,  right 
pneumonia,  fol- 
lowed by  pleural 
effusion.  Lately, 
signs  of  pyo-pneu- 
mothorax. 

Large  left  empyema, 
with  abscess  over 
seventh  and  eighth 
ribs. 


Circumscribed  right 
empyema.  For  the 
last  year,  signs  of 
phthisis. 


Advanced  phthisis. 
In  fifth  left  space, 
in  axillary  line,  a 
fistula  leading  to  a 
very  large  old  em- 
pyema cavity. 


Operation. 


Resection      eighth 
rib  far  back. 


Resection  seventh 
rib.  Drainage  of 
fistulous  track. 

Resection  eighth 
and  ninth  ribs, 
posterior  axillary 
line. 

Puncture  sixth 
space,  posterior 
axillary  line. 


Resection  of 
seventh  and 
eighth  ribs,  pos- 
terior axillary 
line.  Cavity 
lightly  packed 
with  iodoform 
gauze. 

Resection  fourth 
rib  in  front. 


Subperiosteal  re- 
section of  all  ribs 
from  third  to 
tenth,  about  2^ 
inches    of    each. 


Fluid  Let  Out. 


Large  quantity 
of  very  foetid 
pus,  let  out 
slowly. 


About  8  ounces 
of  thick  green- 
ish pus. 


Half  a  pint  of 
viscid  purulent 
fluid. 


Character  of  pus 
not  stated. 


Loculated  cavi- 
ty, extending 
far  and  wide, 
full  of  pus  and 
fungous  granu- 
lations. 


OPERATION    FOR    EMPYEMA. 
Empyema   (up  to   1890) — Continued. 


243 


Result. 


Death  in  a  few  minutes. 


Discharged  with   a   short  extra- 
pleural fistula. 


A  drunkard.  Post  mortem,  foci  of 
gangrene  in  middle  and  lower  lobes. 
Arterial  sclerosis.  Cardiac  throm- 
bosis. 

Empyema  had  been  incised  three 
months  before  operation. 


Taken     home     before    complete      Lung  expanded  well.     Fistula  healed 
healing.  after  scraping  and  drainage. 


Discharged  at  his  own  request; 
cavity  partly  obliterated. 


Healed  in  three  months. 


Discharged  in  two  months  much 
improved,  with  a  small  exter- 
nal fistula. 


Did  well  for  a  week  ;  then  began 
to  sink,  and  died  on  sixteenth 
day  after  operation. 


Effusion     had     never     wholly    dis- 
appeared,   in   spite   of   punctures. 


A  year  before,  he  had  been  treated 
for  '  chronic  abscess '  below  left 
nipple  by  resection  of  a  small  piece 
of  seventh  rib. 


Dulness  reached  from  sternum  to 
axilla,  and  from  second  space  to 
liver.  Puncture  at  first  failed  to 
find  pus,  owing  to  great  thickness 
of  pleura. 


Post  mortem,  Advanced  tuberculous 
phthisis ;  large  cavities  in  left 
upper  lobe.  Tuberculous  ulceration 
of  larynx  and  of  large  intestine. 
Adherent  pericardium.  Throm- 
bosis of  right  femoral  and  external 
iliac  veins. 


2^4 


SURGERY    OF    THE    CHEST. 

Schede's  Cases  of  Operation  for 


No. 


19 


Sex  AND 
Age, 


M.15 


M.  22 


F.  16 


Character  of  Disease. 


Circumscribed  left 
empyema,  pointing 
over  seventh  rib 
in  front :  of  great 
size. 


After  pleurisy,  cir- 
cumscribed right 
empyema,  pointing 
over  sixth  to  eighth 
ribs  in  nipple  line. 

Chronic  left  empye- 
ma, with  fistula  in 
sixth  space,  pos- 
terior axillary  line. 
Advanced  tubercu- 
lous disease  of 
upper  part  of  lung. 


Operation. 


Resection  of  sixth 
and  seventh  ribs, 
at  junction  of 
bone  and  cartil- 
age. Later,  resec- 
tion again  of  sixth 
and  seventh,  and 
later  still,  of 
fourth  and  fifth 
ribs.  Cavity 
lightly  packed 
with  iodoform 
gauze. 

Resection  seventh 
rib.  Later,  cau- 
terization of 
cavity. 

Resection       of 

seventh  to  tenth 
ribs  (24  to  4  ins. 
each),  irrigation, 
scraping,  packing 
with  iodoform 
gauze. 


Fluid  Let  Out. 


Huge  cavity, 
with  enor- 
mously thick- 
ened walls,  and 
numerous 
loculi.  Traces 
of  lung  tissue 
were  found  in 
anterior  wall  of 
cavity  during 
operation. 


Caseous  pus, 
fungous  granu- 
lations, bur- 
rowing sinuses 
in  soft  tissues. 


OPERATION    FOR    EMPYEMA. 
Empyema   (up  to   iSgo) — Continued. 


245 


Remarks. 


Very  slow  recovery,  great  diffi- 
culty in  getting  cavity  to  heal  ; 
completely  closed  in  seven 
months.  Then  he  caught 
diphtheria,  and  died. 


Cavity    closed;     smal     external 
fistula. 


Excellent  recovery  ;  not  only  did 
empyema  heal,  but  lung  was 
greatly  improved. 


Postmortem.  Empyema  healed.  Cavi- 
ties in  both  lungs.  Ulceration  of 
larynx,  probably  tuberculous. 


Discharged   at   own  request :   some 
signs  of  phthisis  at  apices. 


Empyema  had  pointed  and  been 
incised  a  year  before  operation  :  for 
some  months  after  the  incision  she 
had  been  too  ill  for  any  further 
treatment :    then   she    got    better. 


246 


CHAPTER     XVII. 

AFTER    THE    OPERATION. 

The  operation  for  empyema  brings  with  it  the  possibility 
of  fresh  risks  and  difficulties,  and  these  we  may  divide 
under  four  heads:  i.  The  general  co7iditioti  of  the  patient. 
2.  The  tvound.  3.  The  cavity.  4.  The  drainage-tube. 
A  separate  chapter  will  be  necessary  for  those  ultimate 
troubles  of  chronic  fistulous  empyema  which  may 
demand  extensive  resection. 

The  General  Condition  of  the  Patient. 

The  risks  of  death  after  operation,  from  the  general 
condition  of  the  patient,  apart  from  the  special  risks 
of  his  disease,  are  many  and  grave.  The  shock  of  the 
operation  is,  as  a  rule,  somewhat  severe  ^ ;  or  the  case 
may  be  one  of  gangrenous  empyema,  and  the  patient 
may  be  already  under  sentence  of  death  from  acute 
septicsemia.- 

A  man,  aged  25,  waiter  at  a  restaurant,  said  to  be  given  to 
drink,  and  to  have  had  an  attack  of  delirium  tremens,  came 
under  my  care,  having  been  ill  a  fortnight  with  '  pleurisy.' 
He  was  delirious,  half  comatose,  feeble,  plucking  at  the  bed- 
clothes, passing  everything  under  him  ;  tongue  hard  and 
dry,  and  foul  with  thick  black  crusts  ;  temp.  101-102° ;  urine 

'  In  one  of  my  cases,  a  young  man,  aged  20,  the  pulse  during 
operation  shot  up  rapidly  to  160,  and  then  wholly  failed  for  a  few 
moments,  and  he  was  for  a  short  time  in  great  danger. 

=  There  is  an  admirable  article  on  this  form  of  empyema  by 
Dr.  Alexander  James,  in  the  "Transactions  of  the  Medico- 
Chirurgical  Society  of  Edinburgh,"  1890-91. 


AFTER    THE    OPERATION.  247 

albuminous  ;  signs  of  circumscribed  effusion,  left  side  of 
chest.  An  exploratory  puncture  drew  off  thin  purulent  fluid, 
intensely  foetid.  Free  incision,  without  resection,  through  the 
sixth  space,  in  the  posterior  axillary  line,  let  out  more  than  a 
pint  of  thin  greyish-black  .purulent  fluid,  horribly  foetid. 
I  put  in  a  very  large  tube.  Next  day  he  was  no  better  : 
sleepless,  delirious,  comatose  ;  the  cavity  was  still  foetid,  and 
I  washed  it  out  with  warm  boracic  lotion  ;  the  exposed  edge 
of  the  trapezius  was  ashen-grey  and  sloughy.  He  lived  six 
days  longer  ;  never  regained  consciousness,  passed  every- 
thing under  him,  had  to  be  fed  through  the  nose  ;  pulse 
became  intermittent,  diarrhoea  set  in,  chest  ceased  to  move 
in  respiration  ;  he  became  day  by  day  weaker,  and  sank  and 
died  without  ever  becoming  conscious.  His  temperature 
came  down  to  normal  four  days  aiter  the  operation,  but  ran 
up  before  death  to  106°.  The  cavity,  by  repeated  irrigation, 
became  perfectly  sweet  and  dry  soon  after  the  operation,  and 
so  remained  till  death.  A  large  gangrenous  abscess  came 
under  the  trapezius,  and  another  below  and  in  front  of  my 
wound  ;  these  were  duly  opened  and  drained.  The  posi 
mortem  examination  showed  a  dry  empty  clean  cavity, 
perfectly  drained  and  disinfected  ;  a  collapsed,  shrunken, 
airless  lung,  one-third  its  proper  size,  bound  down  and 
packed  away  against  the  spine. 

Here  was  a  case  where  the  patient  had  even  before 
operation  absorbed  so  much  poison  that  he  never  roused 
from  his  typhoidal  state. 

The  other  grave  risks,  arising  from  the  general  con- 
dition of  the  patient,  that  may  spoil  the  success  of  the 
operation,  we  may  best  estimate  by  taking  the  published 
results  obtained  by  different  surgeons.  Eddison,  of 
Leeds,  ^  out  of  31  cases  of  empyema  treated  by  a 
strictly  antiseptic  method,  lost  six  :  three  from  tubercular 
phthisis ;  one  immediately  after  operation,  from  old  cardiac 
and  renal  disease  ;  one,  a  drunkard,  on  the  third  day, 
with  collapse  of  the  lung  ;  and  one,  on  the  fifth  day,  from 
'coalminer's  phthisis.'      Konig,   out  of  76  cases  (1891) 


'  "  Brit.  Med.  Journ.,"   Sept.  29th,  xi 


248  SURGERY    OF    THE    CHEST. 

lost  ten  :  two  from  tubercular  phthisis,  four  from  '  mul- 
tiple abscesses,'  four  from  'other  grave  complications.' 
Hofmokl  (1889),  less  fortunate,  lost  28  cases  out  of  60^ :  of 
these,  13  died  of  tubercular  disease  either  in  the  lungs  or 
elsewhere  ;  6  of  pneumonia ;  3  of  purulent  pericarditis 
and  myocarditis ;  3  of  peritonitis  ;  one  each  of  amyloid 
disease  and  shock,  paralysis  of  the  heart,  and  malignant 
disease.  I  have  had  3  deaths  :  two  have  already  been  re- 
corded, the  third  was  from  tubercular  phthisis  a  few  weeks 
after  the  empyema  had  healed.  It  is  to  be  noted  that 
the  ways  of  death  after  the  operation  for  empyema,  so 
far  as  the  general  condition  of  the  patient  is  concerned, 
come  either  from  acute  septicaemia  or  pyaemia,  from 
amyloid  disease,  or  from  organic  disease. 

Of  the  acute  septic  processes  that  may  follow  empyema, 
before  or  after  operation,  true  pyaemia  is  rare  indeed, ^ 
and  we  need  not  fear  the  possibility  of  it.  Acute  septi- 
caemia, in  the  days  before  Lister,  was  terribly  common  ; 
the  discharge  from  the  cavity  becomes  thin,  greyish, 
perhaps  haemorrhagic  or  foetid ;  the  wound  becomes 
indolent,  pale,  and  sloughy  ;  fever,  diarrhoea,  delirium, 
and  prostration  mark  the  beginning  of  the  end.  We  may 
hope  that  such  a  way  of  death  is  now  closed,  save  for 
cases  of  gangrenous  empyema ;  the  danger  of  '  pleural 
septicaemia  '  arises  almost  wholly  from  imperfect  drainage 
and  wrong  methods  of  surgery. 

Among  the  septic  processes  that  may  follow  empyema 
we  must  also  reckon  the  formation  of  abscesses  in  the 
lung,  as  in  one  of  Schede's  list  of  cases ;  and  that  most 
strange    connection    between    empyema    and    cerebral 


'  Hofmokl's  60  cases  of  '  major  operations  on  the  thorax  '  in- 
clude one  or  two  that  were  not  empyema. 

' '  I  have  only  in  one  case  met  with  metastatic  abscesses  else- 
where than  in  the  brain.'     Godlee,  1892. 


AFTER    THE    OPERATION.  249 

abscess.  Sir  William  Gull  ^  first  called  attention  to  the 
lact  that  cerebral  abscess  is  common  after  suppuration 
within  the  chest :  Schede  records  two  cases  after 
empyema;  Mr.  Godlee  (1892)  records  five,  and  points 
out  that  abscess  of  the  brain  does  not  necessarily  follow 
soon  after  an  operation  on  the  ribs,  and  moreover  may 
be  quite  independent  of  surgical  interference ;  that  one 
side  of  the  brain  is  not  more  often  affected  than  the 
other,  nor  one  part  of  it  more  than  another.  Similar 
cases  have  been  recorded  by  Dr.  West  and  Dr.  Finlay. 
This  curious  affinity  between  the  brain  and  the  thoracic 
organs  is  an  instance  how  relations  between  remote 
organs,  unknown  in  health,  may  be  made  manifest  by 
disease.  It  cannot  be  explained  by  any  theory  of 
mechanical  disturbance  of  the  cerebral  circulation,  nor 
by  any  general  reference  to  septic  embolism  ;  nor  is  it  a 
matter  of  chance.  One  thing  is  certain,  that  the  locali- 
zation of  pyremic  abscesses  does  not  take  place  in  a 
purely  haphazard  fashion.  Some  years  ago  •  I  tabulated 
the  distribution  of  the  abscesses  in  nearly  200  cases  of 
pyaemia,  and  found  evidence  that  in  pyaemia,  as  in 
malignant  disease,  though  the  elements  of  the  disease 
may  be  disseminated  over  the  whole  body,  they  grow 
better  on  some  soils  than  on  others. 

Amyloid  disease  we  only  know  in  cases  of  chronic 
fistulous  empyema  ;  and  the  examples  in  general  surgery 
of  recovery  from  this  disease,  after  the  cause  has  been 

'"Guy's  Hospital  Reports,"  1857.  For  references  to  more 
recent  records  and  opinions,  see  "Clinical  Society's  Proceedings," 
Jan.  25th,  1884,  and  "Medical  Society's  Proceedings,"  Feb.  8th, 
1886. 

^  "  Distribution  of  Pyaemic  Abscesses,"  "Lancet,"  1886;  "Dis- 
tribution of  Secondary  Growths  in  Cancer  of  the  Breast," 
"  Lancet,"  1889.  We  must  remember  that  a  septic  embolus  from 
the  lung  would  pass  along  a  pulmonary  vein  to  the  left  side  of  the 
heart,  and  thus  be  able  to  reach  the  brain. 


250  SURGERY    OF    THE    CHEST. 

removed  by  operation,  show  that  its  presence  does  not 
necessarily  go  against  an  extensive  resection  of  ribs,  if  the 
cavity  of  the  empyema  cannot  in  any  other  way  be  closed. 
We  must  remember  that  albuminuria  in  empyema  may 
have  some  other  source  than  amyloid  disease. 

Of  the  organic  diseases  that  may  lead  a  case  of 
empyema  to  end  in  death,  the  most  common  are  tuber- 
cular phthisis,  chronic  valvular  disease  of  the  heart,  and 
chronic  nephritis ;  and  it  is  certain  that  the  results  of 
drink  tell  very  heavily  against  a  case  of  empyema.  The 
frequency  of  tubercular  phthisis  we  have  already  reckoned  ; 
but  we  must  in  each  phthisical  patient  endeavour  to 
make  out  whether  we  are  dealing  with  a  tubercular 
empyema,  or  with  an  empyema  in  a  tubercular  patient. 
True  primary  tubercular  disease  of  the  pleura,  a  diffuse 
tuberculosis  arising  on  the  pleural  surface,  or  in  the  false 
membranes  of  an  old  pleurisy,  may  either  run  its  course 
unheeded  as  part  of  a  rapidly  fatal  general  tuberculosis, 
or  may  be  suspected  during  life,  yet  hard  to  diagnose, 
and  still  harder  to  treat  with  any  permanent  success. 
Every  case  of  pleurisy  in  a  patient  likely  from  his  history 
or  inheritance  to  be  phthisical  must  be  viewed  with 
anxiety,  especially  if  there  be  anything  unusual  in  the 
course  or  extent  of  the  inflammation,  or  any  relapse  ;  and 
careful  microscopic  examinations  must  be  made  of  the 
fluid,  if  there  be  effusion.  In  cases  where  it  seems 
probable  that  the  pleura  only  is  affected,  the  best  hope 
for  the  patient  may  perhaps  be  a  free  incision  into  the 
pleura,  and  free  drainage ;  but  the  chance  of  recovery, 
when  once  the  disease  is  well  established,  is  very  small. 
The  hope  is  slightly  better  in  pleural  effusion  due  to  pul- 
monary phthisis,  but  still  very  doubtful.  '  I  have  come  to 
believe,'  says  Hofmokl  (1889)  'that  the  surgery  of  the 
lung  and  of  the  pleura  in  tubercular  patients,  at  all  events 


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AFTER    THE    OPERATION.  251 

as  things  are  at  present,  does  not  give  us  much  hope  of 
success.'  On  the  other  hand,  out  of  Schede's  four  cases 
of  empyema  in  acute  phthisis,  the  empyema  was  healed 
by  operation  in  three ;  the  fourth  patient  died  of 
pulmonary  embolism  from  thrombosis  of  the  femoral 
vein ;  in  one  of  my  own  cases,  the  empyema,  which 
was  already  pointing  outward,  healed  quickly.  Whether 
aspiration,  or  free  incision,  shall  be  used  for  effusions  in 
cases  of  phthisis  must  depend  to  some  extent  on  the 
character  of  the  fluid  and  the  stage  of  the  disease  in  the 
lung.  Two  things  are  to  be  noted  in  these  cases  :  first, 
the  difficulty  of  deciding  whether  the  sounds  at  the  apex 
of  the  lung  are  due  to  phthisis,  or  simply  to  pressure 
of  the  effusion  on  the  rest  of  the  lung;  next,  the 
possibility  that  sudden  withdrawal  of  a  large  effusion 
from  a  phthisical  patient  may  cause  hsemorrhage  from  a 
cavity  in  the  lung,  as  in  the  following  case '  : — 

'  I  once  saw  fatal  hEemorrhage  from  the  lung,  eight  hours 
after  aspiration  of  the  chest.  The  patient  was  a  man  23 
years  old,  in  advanced  phthisis,  with  large  cavities  in  the 
leit  lung,  somewhat  extensive  caseation  of  the  right  lung,  and 
very  feeble  ;  then  came  signs  of  a  left  pleural  effusion,  and  a 
week  later  there  was  oedema  of  the  left  side,  intense  pain, 
temperature  106°.  Operation,  from  the  state  of  his  lungs, 
was  deferred  for  another  week  ;  then  2;^  pints  were  with- 
drawn, to  his  great  relief.  Eight  hours  later,  there  came  a 
furious  haemorrhage  through  the  mouth,  and  he  died  in  a 
few  minutes.  Post  moriem,  rupture  of  a  small  aneurysm  in 
the  wall  of  one  of  the  cavities  in  the  left  lung.' 

The  two  drawings  {F/aie  VI.)  show  the  hopeless 
course  of  most  cases  of  '  tubercular  pleurisy.'  In  one  of 
them  the  pleura  is  riddled  by  the  outw^ard  spread  of 
infection  from  the  lung ;  in  the  other,  a  true  tuberculosis 
of  the  pleura,   it  is  invaded  over  its  whole  extent  by 

'  Frantzel,  "  Ziemssen's  Handbuch"  (1875). 


252  SURGERY    OF    THE    CHEST. 

masses  of  caseous  tubercle.  With  such  cases  as  these, 
surgery  can  at  most  only  alleviate  suffering,  as  by  the 
aspiration  of  an  effusion  ;  but  if  one  had  to  deal  with  an 
early  stage  of  tuberculosis  of  the  pleura,  without  evident 
disease  of  the  lung,  it  is  possible  that  free  opening 
and  irrigation  of  the  cavity  might  do  good,  just  as  they 
sometimes  arrest  or  cure  tubercular  disease  of  the 
peritoneum. 

We  have  now  considered  some  of  the  dangers  after 
operation  for  empyema  that  depend  on  the  general  con- 
dition of  the  patient ;  next  come  the  troubles  to  which 
the  wound  may  give  rise. 

The  Wound  after  Operation. 

Excoriation  round  the  wound  is  not  common,  and  may 
be  avoided  by  the  use  of  some  simple  ointment,  which  is 
better  than  collodion.  If  anything  could  be  sure  to  pro- 
duce it,  this  would  be  the  lotion  of  biniodide  of  mercury, 
which  I  have  seen  in  several  cases  cause  sharp  inflamma- 
tion of  the  skin,  nor  can  I  find  that  it  has  the  slightest 
advantage  over  less  irritant  lotions. 

Suppuration  in  the  soft  parts  round  the  wound  is  also 
very  rare  ;  it  comes  sometimes  of  not  making  a  free, 
clean,  well-placed,  smooth-edged  incision  without  rough 
handling  of  the  tissues,  or  of  neglect  of  antiseptic  sur- 
gery. If  it  occurs,  it  is  usually  below  the  wound,  and 
may  be  accompanied  by  some  slight  emphysema.  In 
cases  of  gangrenous  empyema,  it  is  almost  sure  to  occur. 

A  young  married  woman,  aged  20,  came  under  my  care  in 
1894.  Eight  weeks  before,  labour  had  been  induced  on 
account  of  convulsions  ;  a  fortnight  after  this,  she  '  caught 
cold,'  and  became  feverish,  with  pain  in  the  left  side,  and 
cough.  She  was  admitted  to  Hospital  on  the  14th  of  July, 
with  dulness  over  the  lower  half  of  the  left  side,  and  dimin- 
ished vocal  vibration  ;   but  vocal  resonance  was  increased 


AFTER    THE    OPERATION.  253 

and  breath-sounds  and  fine  crepitations  could  be  heard  over 
the  dull  area.  On  the  19th  and  again  on  the  24th,  a  small 
quantity  of  blood-stained  fluid  was  withdrawn  on  aspiration. 
She  now  became  worse,  with  profuse  sweatings,  diarrhoea, 
sickness;  temp.  102-104°,  pulse  144;  and  on  the  29th,  aspira- 
tion followed  loy  incision  of  the  ninth  space  in  the  posterior 
axillary  line  let  out  24  ounces  of  thin  greyish-black  purulent 
fluid,  of  horribly  gangrenous  smell.  On  August  2nd,  a  swelling 
below  the  scapula  was  incised,  but  no  fluid  was  found  in  it. 
For  a  few  days  she  improved  ;  then  again  became  worse, 
with  delirium,  profuse  diarrhcjea,  and  great  prostration,  and 
there  were  also  signs  of  pneumonia  at  the  base  of  the 
opposite  lung.  On  August  12th,  a  large  collection  of 
gangrenous  pus  was  opened  and  drained,  near  the  lower 
angle  of  the  scapula,  and  on  the  14th  another  collection,  two 
or  three  inches  below  the  wound,  was  treated  in  the  same 
way.  From  August  7th  to  14th,  she  was  in  great  danger, 
but  she  finally  made  a  complete  recovery. 

It  is  in  such  cases  that  there  is  risk  of  haemorrhage 
from  ulceration  of  the  intercostal  artery  from  pressure  of 
the  tube  ;  and  Mr.  Godlee  advises  that  the  artery  should 
be  divided  and  tied  at  the  operation,  if  the  effusion  be 
found  gangrenous. 

Caries  or  necrosis  of  the  ribs,  though  several  causes 
may  possibly  produce  it,  is  seldom  seen.  It  may  follow 
infection  from  an  empyema  pointing  outward,  or  pres- 
sure of  the  tube,  or  infection  of  the  cut  ends  of  the 
rib  after  resection  ;  but  with  the  use  of  soft  tubes  and 
antiseptic  methods  it  has  become  rare  ;  and  its  occurrence 
after  resection  may  perhaps  be  due  sometimes  to  an 
unskilful  division  of  the  rib.  In  ^\ post  mortem  examin- 
ations at  Great  Ormond  Street  Hospital,  there  was  only 
one  instance  of  necrosis  of  rib  after  resection,  and  three 
of  caries  of  rib  from  prolonged  pressure  of  the  tube  after 
simple  incision  without  resection ;  but  20  of  the  54 
died  of  tubercular  disease,  and  it  is  possible  that  the 
caries  may  sometimes  be  due  to  tubercular  infection. 

Exuberant  Callus. — We  are  more  likely  to  get  trouble 


254  SURGERY    OF    THE    CHEST. 

from  a  resected  rib  closing  up  than  from  its  breaking 

down,  especially  if  we  have  been  careful  to  save  every 

shred  of  periosteum  ;    and  I  have  been   compelled  on 

more  than  one  occasion  to  do  resection  a  second  time. 

A  young  man,  aged  20,  was  taken  ill  about  Christmas, 
1893,  with  right  pleurisy  ;  two  pints  of  fluid  were  aspirated, 
and  he  was  in  bed  for  six  or  seven  weeks.  In  April,  1894, 
he  came  under  my  care  with  empyema  pointing  over  the 
seventh  and  eighth  right  spaces  in  the  anterior  axillary  hne, 
and  dulness  over  the  lower  half  of  the  chest ;  no  oedema,  no 
bulging  of  the  spaces.  The  swelling  had  been  diagnosed  as 
a  simple  abscess.  I  incised  it,  but  could  not  find  the  opening 
into  the  pleura,  so  resected  the  eighth  rib  in  the  line  of  the 
scapula,  and  let  out  two  pints  of  pus.  The  pleura  was  much 
thickened,  the  rib  very  broad  and  thick,  and  hard  to  cut. 
The  abscess  in  front  healed  very  quickly  ;  behind,  a  sinus 
formed,  running  backward  and  upward  for  three  and  a  half 
or  four  inches  toward  the  spine.  It  was  kept  open  witli 
a  pewter  drain,  and  became  so  narrow  and  rigid  that  it  was 
difficult  at  last  to  pass  anything  along  it.  In  June,  1894,  I 
laid  it  freely  open,  and  resected  about  an  inch  and  a  half  of 
the  eighth  and  ninth  ribs,  and  found  the  eighth  rib  so  restored 
that  there  was  only  a  central  foramen  through  a  mass  of 
callus  ;  the  walls  of  the  sinus  were  almost  as  hard  as 
cartilage  :  I  cut  away  a  part  of  them  and  dilated  the  whole 
track.     He  now  healed  quickly. 

The  Cavity  after  Operation. 

Something  has  already  been  said  of  ill-placed  or  in 
sufficient  drainage  :  the  final  failure  of  a  cavity  to  close, 
and  the  treatment  of  this  condition,  will  be  put  in  the 
next  chapter.  For  the  present,  there  are  four  other 
subjects  to  be  considered:  (i)  the  continuance  of 
profuse  or  foetid  discharge  after  operation,  (2)  the  risk 
of  absorption  of  lotion  used  for  irrigation,  (3)  the  risk  of 
haemorrhage,  (4)  the  troubles  that  may  come  directly  from 
irrigation. 

Profuse  or  Fxtid  Discharge  continuing  after  Operation. 
— The  contents  of  the  cavity  are  seldom  foetid  at  the  time 


AFTER    THE    OPERATION.  255 

of  operation,  unless  there  be  advanced  disease  of  the 
lung,  or  the  empyema  be  due  to  infection  from  the 
abdominal  cavity  :  and  if  fcetor  be  first  observed  some 
days  afterward,  probably  the  drainage  is  at  fault,  and 
there  has  been  neglect  of  a  proper  method  of  dressing 
the  wound  :  and  this  may  lead  to  retention  of  large 
masses  of  infected  fibrin.  For  example,  in  1878,  Starcke 
published  the  case  of  a  man,  aged  23,  with  empyema  of 
the  right  side  after  pneumonia ;  incision  let  out  more 
than  four  pints  of  greenish  sero-purulent  fluid.^  Four 
days  later,  he  again  became  feverish,  a  piece  of  rib  was 
resected,  and  two  great  foetid  masses  of  fibrin  were  found 
and  removed. 

If  we  cannot  render  the  discharge  inoffensive,  by  re- 
moval of  fibrin  and  by  gentle  irrigation,  or  if  it  remain 
profuse  for  some  weeks  after  the  operation,  we  may  do 
well  to  pack  the  cavity  lightly  with  a  long  strip  of  gauze. 
Wagner  -  for  this  purpose  uses  a  single  strip,  many  feet 
long,  of  weak  iodoform  gauze :  he  advocates  it  in  any 
case  where  the  cavity  is  not  closed  six  weeks  after  the 
operation,  or  troubles  and  failures  arise  over  the  drainage, 
or  the  discharge  remains  profuse.  The  iodoform  arrests 
the  suppuration,  and  the  soft  gauze,  loosely  packed,  does 
not  hinder  the  obliteration  of  the  cavity.  He  makes 
light  of  the  fear  of  iodoform-poisoning  ;  but  since  two  of 
Schede's  patients,  after  very  extensive  operations,  suffered 
from  it,  and  one  died,  it  would  be  safer  to  use  some  other 


'  In  1878,  the  use  of  the  spray  was  so  faithfully  observed  that 
the  patient  was  kept  sitting  up  exposed  to  it  for  three  hours,  till 
all  the  fluid  was  drained  out  of  his  chest. 

^Victor  Wagner:  "Die  Behandlung  der  Empyeme  mittelst 
lodoformmull  Tamponade."  "Wien.  Khn.  Wchnschr. ,"  1891, 
p.  609.  Schede  has  used  naphthalin-gauze  ;  or  izal-gauze  might 
be  tried.  Carbolic-gauze  would  not  be  free  from  the  risk  of 
poisoning. 


256  SURGERY    OF    THE    CHEST. 

kind  of  gauze.      His  cases  are  so  valuable  that  I  give  an 
abstract  of  them. 

1.  A  man  shot  himself  (Jan.  27th,  1880)  in  the  sixth  left 
space  in  the  nipple  line  ;  the  bullet  passed  out  behind  ;  there 
was  free  hseinorrhage  ;  air  passed  in  and  out  of  the  wound, 
and  emphysema  spread  slowly  over  the  whole  trunk.  He 
did  well  for  a  week,  then  began  to  suffer  pain,  fever,  and 
sloughing  of  the  wound  ;  and  when  he  sat  up,  thin  greenish 
foetid  fluid  poured  from  it,  soaking  the  dressings  and  the 
bedclothes.  Feb.  8th,  he  was  very  feeble,  cyanosed,  and 
breathing  with  difficulty  ;  a  piece  of  the  sixth  rib  was  re- 
sected, in  the  anterior  axillary  line,  and  the  cavity  was 
irrigated,  washed  with  iodoform  emulsion,  and  drained  ;  but 
no  marked  improvement  followed.  Feb.  19th,  several  feet 
of  iodoform  gauze  were  loosely  packed  into  the  cavity,  and 
renewed  at  first  daily,  then  every  other  day.  '  The  result 
was  extraordinary  :  the  formation  of  fibrinous  clots  ceased  at 
once,  the  discharge  became  less,  and  his  general  condition 
rapidly  improved.'  By  April,  there  was  only  a  fistula  ;  by 
May,  he  was  fully  healed. 

2.  A  man,  aged  23,  had  empyema  of  the  right  side  after 
pneumonia  ;  a  piece  of  the  sixth  rib  was  resected  in  the 
anterior  axillary  line,  and  2_J2  pints  of  pus  were  let  out.  At 
first,  all  went  well  ;  but,  in  spite  of  irrigations  and  iodoform 
emulsion,  the  discharge  remained  profuse,  and  for  five 
months  nothing  could  check  it.  After  this,  a  large  flap  was 
raised,  pieces  of  the  sixth  and  seventh  ribs  were  resected, 
thickened  pleura  was  cut  away,  and  the  cavity  was  scraped. 
Still  the  profuse  discharge  went  on.  A  fortnight  later,  the 
cavity  was  packed  with  iodoform  gauze.  In  a  few  weeks  it 
was  entirelv  healed. 

3.  A  man,  aged  39,  had  empyema  of  the  right  side  after 
pneumonia  ;  incision  and  resection  of  sixth  rib  in  the 
anterior  axillary  line  let  out  3^!^  pints  of  pus  ;  there  re- 
mained a  fistula,  and  two  and  a  half  months  after  operation, 
as  it  was  still  open,  and  necrosed  bone  could  be  felt  through 
it,  a  further  resection  was  made  ;  but  the  fistula  did  not 
appear  to  be  deep,  and  the  wound  was  therefore  closed.  A 
fortnight  later  (July  15th)  he  began  to  be  feverish  ;  the  ribs 
were  so  fallen  together  that  a  probe  could  not  be  passed 
between  them  ;  his  general  health  was  good  ;  he  refused 
further  operation.'  Aug.  i6th,  during  the  night,  there  was  a 
sudden  breaking  of  pus  into  the  lung,  causing  great  prostra- 
tion.    Aug.  2ist,  resection  of  pieces  of  eighth  and  ninth  ribs 


AFTER    THE    OPERATION.  257 

let  out  nearly  a  pint  of  pus  ;  the  cavity  appeared  to  be 
bi-locular,  one  part  almost  healed,  the  other  opening-  into  the 
lung.  Troubles  now  arose  over  the  drainage  :  a  soft  tube 
got  compressed,  a  silver  one  was  pushed  out,  and  the  use  of 
iodoform  emulsion  caused  cough,  pains  in  the  neck,  and  a 
persistent  taste  of  iodoform  in  the  mouth.  At  last,  strips  of 
iodoform  gauze  were  used,  and  under  this  treatment  the 
fistula  was  healed. 

These  excellent  cases  of  Wagner's  ought  to  be  studied 
not  only  for  their  own  sake,  but  also  because  they  suggest 
a  way  of  escape,  short  of  operation,  for  the  patient  who  is 
threatened  with  chronic  fistulous  empyema. 

Risk  of  Absorptioti  of  Lotion. — And  as  they  raise 
the  subject  of  iodoform  poisoning,  we  may  here  note 
the  plain  duty  of  the  surgeon  to  avoid  the  use  of 
poisonous  lotions  in  a  large  cavity.^  The  lotions  that 
have  been  from  time  to  time  in  favour  are  innumerable — 
iodine,  iodide  of  potassium,  alcohol,  chlorinated  soda, 
lime-water,  eucalyptus,  salicylic  acid,  zinc,  silver  nitrate, 
and,  above  all,  carbolic  acid  and  perchloride  of 
mercury — and  many  others.  Majendie  showed  long 
ago  that  the  healthy  pleura  absorbs  poison  even  more 
swiftly  than  the  peritoneum  ;  the  absorption  of  serous 
effusions,  and  the  terrible  frequency  of  acute  septicaemia 
after  operation  for  empyema  before  Lister's  time,  show 
that  it  does  not  necessarily  lose  its  power  of  absorption 
in  disease,  though  of  course  a  chronic  thick-walled  cavity 
is  practically  non-absorbent.  Carbolic  acid  heads  the 
list,  in  the  records  of  poisoning  after  irrigation  of  the 
pleura  ;  iodine  was  often  the  cause  of  it,  at  the  time 
when  its  use  was  common  ;  iodoform  has  several  times 
caused  it ;  and  since  a  collection  has  lately  been 
made  of  no  less  than  35  cases  of  mercurial  poisoning 

'  On   the   whole   of  this    question,    see    especially    Bouveret, 
"  Traite  de  rEmpyeme." 

i7 


258  SURGERY    OF    THE    CHEST. 

after  abdominal  operations,  it  is  evident  that  the  per- 
chloride  lotion  is  unsafe  also  in  empyema.  I  use  either 
boracic  lotion  or  Condy's  fluid  ;  as  to  iodoform  emulsion 
of  glycerine,  I  admit  that  it  can  become  well  diffused 
over  the  whole  cavity,  for  in  my  own  case  of  fatal  gan- 
grenous empyema,  the  crystals  were  found  post  fjioriem 
scattered  even  over  the  very  summit  of  the  pleura ;  but 
it  is  an  uncertain  preparation,  and  of  very  doubtful 
value  :  '  a  lot  of  it  runs  out  at  once,  some  more  is 
expelled  by  coughing,  and  a  small  portion  of  it  may 
remain  in  the  chest  without  doing  any  harm.'  I  quote 
Hohnokl's  opinion  against  the  glycerine  emulsion  of 
iodoform  ;  but  I  would  rather  not  follow  his  astonishing 
advice,  to  use  a  mixture  of  iodoform  in  ether,  and  then 
plug  the  wound,  being  prepared  to  take  out  the  plug 
if  there  should  be  any  fear  of  the  ether  expanding ! 

Hcemorrhage  from  the  Cavity. — Anything  more  than  a 
very  slight  transient  oozing,  from  the  granulation  tissue, 
or  from  recent  adhesions,  is  very  rare  :  yet  one  or  two 
cases  have  been  recorded  of  serious  hgemorrhage  ;  and  if 
the  blood  does  not  come  from  an  intercostal  vessel, 
the  hope  of  finding  the  source  of  it  is  small  indeed. 
In  one  of  Schede's  cases,  very  profuse  haemorrhages 
occurred  on  the  third  and  fourth  days  after  the  opera- 
tion, and  the  patient  died  on  the  fifth  day.  The 
post  mortem  examination  showed  abscesses  in  the  lung, 
but  the  source  of  the  hgemorrhage  was  not  discovered. 
In  four  cases,  collected  by  Bouveret,  many  weeks  or 
months  had  passed  since  the  operation.  I  give  three 
of  them  : — 

I.  A  boy,  aged  16,  had  empyema  of  the  right  side,  which 
was  followed  by  a  fistula  ;  this  was  treated  (1875)  hy  drain- 
age and  counter-opening.  About  three  weeks  later,  blood 
began  to  flow  from  the  fistula,  at  first  in  small  quantities, 
then  more  profusely,  so  that  in  a  week  he  was  exhausted  and 


AFTER    THE    OPERATION. 


259 


in  imminent  danger  of  death.  Pieces  of  two  ribs  were 
therefore  resected,  and  the  cavity,  as  no  bleeding  point  could 
be  found,  was  plugged  with  no  less  than  eighty  pledgets  of 
charpie,  arranged  kite-tail  fashion  on  a  long  thread.  They 
were  removed  on  the  tenth  day.     He  made  a  good  recovery. 

2.  A  man,  aged  29,  had  a  pointing  empyema  of  the  right 
side,  which  was  incised  (1875),  but  a  fistula  remained. 
He  recovered  so  far  as  to  get  back  to  work  ;  then,  one  night, 
woke  with  profuse  ha;mon-hage  from  the  fistula  :  the  blood 
flowed  steadily  for  half-an-hour,  and  kept  oozing  for  two 
days.  A  day  or  two  later,  he  was  seized  with  right  paraplegia, 
partial  aphasia,  and  loss  of  memory,  plainly  due  to  cerebral 
embolism. 

3.  A  young  man,  after  hydro-pneumothorax,  probably 
due  to  tubercular  disease,  had  empyema,  which  was  treated 
(1881)  by  repeated  punctures.  In  Nov.  1881,  a  piece  of  rib 
was  resected.  During  the  operation,  the  intercostal  artery 
was  wounded,  and  was  secured.  Dec.  i88i,it  was  necessary 
again  to  do  resection.  March  1882,  rather  severe  haemor- 
rhage occurred,  but  it  was  stopped  with  the  use  of  ergotin 
and  cold  irrigations. 

This  late  bleeding  from  an  unhealed  empyema  is  so 
rare  that  one  need  not  fear  it.  Should  it  be  so  persistent 
and  profuse  as  to  demand  active  treatment,  the  surgeon 
must  bear  in  mind  the  possibility  that  it  may  come  from 
an  intercostal  artery,  not  from  the  deeper  parts  of  the 
cavity. 

Troubles  that  may  come  of  Irrigation. — I  believe  that 
irrigation  of  an  empyema  should  be  done  only  if  there 
is  some  special  reason  for  it,  and  I  have  long  ago  given 
it  up  in  ordinary  cases.  A  rough  irrigation  may  cause 
bleeding  from  the  cavity,^  or  may  break  a  recent  adhesion. 

'  Bouveret  gives  the  case  of  a  boy,  aged  18,  with  empyema 
after  pleurisy.  During  irrigation,  the  fluid  became  first  blood- 
stained, then  almost  pure  blood.  The  bleeding  stopped  with  the 
use  of  a  cold  lotion.  I  know  of  a  similar  case,  a  young  man, 
whose  empyema  had  been  washed  out  daily  for  a  week  after 
operation.  One  day  later,  during  irrigation,  he  suddenly  had  a 
fit  of  coughing,  a  sharp  pain  in  his  side,  and  a  foul  taste  in  his 
mouth  ;  he  coughed  up  a  streak  of  blood,  and  for  some  hours  felt 
uneasy  and  depressed,  but  no  harm  came  of  it. 


26o  SURGERY    OF    THE    CHEST. 

Again,  if  there  be  an  opening  into  the  lung,  irrigation 
may  cause  grave  trouble.  Again,  the  careless  use  of 
cold  lotion  for  irrigation  may  be  followed  by  the  most 
disastrous  results  :  I  have  heard  of  a  case  where  death 
followed  almost  at  once. 

One  great  danger  of  irrigation — that  it  may  suddenly 
cause  syncope,  or  convulsions,  or  even  death— we  must 
consider  at  some  length,  carefully  noting  the  chief 
features  of  those  cases  where  it  has  occurred. 

In  the  first  place,  we  must  note  that  there  are  other 
reflex  changes,  short  of  syncope  or  convulsions,  that  may 
lead  us  to  a  right  view  of  the  whole  subject.  I  am  not 
speaking  of  the  wasting  of  the  muscles  in  the  neighbour- 
hood— the  pectorales,  serratus,  and  shoulder-muscles, 
and  even  those  of  the  arm — which  has  sometimes  been 
noted  in  empyema,  and  is  analogous  to  the  wasting  of 
the  muscles  round  an  inflamed  joint :  nor  of  weakness,  or 
choreic  moveiments  in  the  upper  or  lower  limb,  or  in 
both,  on  the  affected  side  of  the  body,  coming  on  slowly 
after  the  operation,  as  has  been  recorded  in  three  cases^  : 
but  there  are  slight  reflex  disturbances  directly  due  to 
irrigation.  Thus,  in  one  case,"  a  youth,  aged  19,  with 
empyema  of  the  right  side,  every  irrigation  was  followed 
by  a  rise  of  temperature  to  100*^;  in  another,  the  tem- 
perature rose,  after  a  single  irrigation,  to  104^*,  but  came 
back  to  normal  the  next  day ;  in  several,  there  have  been 

'  Lepine,  "  Note  sur  un  Etat  Paretique  developpe  dans  les 
membres  du  cote  correspondant  a  rempyeme."  "  L' Union 
Medicale,"  Feb.  ist,  1876.  It  is  of  interest  to  note  that  hemiplegia 
may  occur  in  pneumonia  in  aged  people,  as  a  '  sympathetic 
phenomenon,  without  any  corresponding  cerebral  lesion.'  See 
"Charcot's  Lectures  on  Senile  Diseases,"  Syd.  Soc.  Transl. , 
p.  38. 

=^  Baum,  "  Berl.  Klin.  Wchnschr.,"  Nov.  1877;  see  Bouveret, 
and  Slajner.  Also  Dr.  Sear's  paper,  Boston  Med.  Surg.  Jour., 
August  31st,  1893. 


AFTER    THE    OPERATION.  261 

curious  vaso-motor  changes — patches  of  redness,  oedema, 
or  sweating  of  the  neighbouring  skin.^ 

These  shght  and  transient  disturbances  of  the  tempera- 
ture, or  of  the  vaso-motor  system,  seem  clearly  to  show- 
that  the  occurrence  of  syncope,  convulsions,  even  death, 
after  irrigation,  is  also  due  to  reflex  action.  The  other 
explanations  that  have  been  put  forward — cerebral  embo- 
lism, epilepsy,  acute  poisoning  with  carbolic  acid — are 
none  of  them  adequate.  But,  above  all,  we  must  note 
that,  in  nearly  all  of  these  cases,  it  was  especially  recorded 
that  an  excessive  quantity  of  lotion  was  used,  or  the 
irrigation  was  given  somewhat  roughly,  or  the  patient 
complained  of  pain. 

The  first  case  recorded  in  England  ('Clin.  Soc.  Trans.,' 
vol.  X.,  page  16)  was  Dr.  Cayley's,  in  1877  ;  Raynaud 
and  Vallin  had  published  three  cases  two  years  earlier ; 
Bouveret,  in  1888,  collected  18  ;  and  several  have  been 
published  since.  From  this  wealth  of  evidence,  I  quote 
the  following  examples  : — 

1.  A  man,  aged  36,  with  circumscribed  empyema  of  the 
right  side,  was  treated  (1877)  with  repeated  punctures,  the 
cavity  being  each  time  irrigated  through  the  cannula  with  a 
weak  iodine  sokition.  After  six  weeks  of  this  treatment, 
a  rather  larger  quaiitity  of  the  lotion  was  one  day  injected  to 
measure  the  cavity.  He  was  at  once  seized  with  convulsions, 
his  temperature  ran  up  to  107°,  and  he  died  in  sixteen  hours. 

2.  A  man,  aged  23,  with  empyema  of  the  left  side,  was 
treated  (1875)  by  incision,  followed  by  irrigation  with  car- 
bolic lotion.  On  the  fifth  day  after  the  operation,  irrigation 
was  followed  by  pain.,  syncope,  convulsions,  opisthotonos, 
and  death  in  six  hours. 

3.  A  man,  aged  27,  with  left  empyema,  was  treated  (1873) 
by  incision  followed  by  irrigation  with  alcoholized  water. 
On  the  eleventh  day,  irrigation,  while  he  sat  up  in  bed, 
was  followed  by  syncope  ;    he   revived,   and   that   evening 

'Goodhart,  "  Guy's  Hosp.  Reports,"  1877. 


252  SURGERY    OF    THE    CHEST. 

he  was  again  set  up,  aiid  again  irrigated;  syncope,  followed 
by  convulsions,  trismus,  conjugate  deviation  of  eyes  to  right, 
sweating,  stertorous  breathing,  and  coma  ;  eight  hours  later, 
a  fresh  attack  of  epileptiform  convulsions,  and  death  in  three 
hours. 

4.  A  girl,  aged  16,  with  right  empyema,  was  treated 
(1875)  by  puncture,  drainage,  and  irrigation  with  carbolic 
lotion.  On  the  thirty-fourth  day,  irrigation  luhile  she  sat  up 
171  bed,  was  followed  by  syncope,  without  convulsions.  An 
hour  later  it  was  noted  that  the  right  side  of  the  face, 
and  the  right  arm  and  hand,  were  white  and  swollen,  but 
this  soon  disappeared.  Sweating  of  the  head  and  neck, 
slight  contraction  of  the  arms,  transient  paralysis  of  the  right 
side  of  the  face,  were  also  noted  ;  pupils  equal,  answering  to 
light,  contracted  at  first,  dilated  afterward  ;  no  strabismus  ; 
no  convulsions.  She  never  regained  consciousness,  and 
died  in  nine  hours. 

5.  A  young  married  woman,  just  delivered  of  a  child,  had 
empyema  of  the  right  side,  treated  (1881)  by  incision  and 
irrigation  (carbolic  acid,  alcoholized  water,  iodine,  at  different 
times).  On  the  thirty-second  day,  a  rather  larger  quatitity  of 
fluid  was  injected;  this  was  followed  by  headache,  dulness, 
and  large  roseolar  patches  over  the  face  and  limbs  ;  and 
these  strange  results  occurred  again  and  again  after  irriga- 
tion for  several  days  ;  but  they  did  ?tot  appear  after  special 
care  had  been  taken  to  make  the  irrigation  very  gently.  On 
the  forty-second  day  this  precaution  was  neglected;  again 
she  had  headache,  and  felt  confused,  and  the  same  rash 
appeared  on  her  face,  chest,  and  arms ;  a  minute  or  two 
later  she  gave  a  cry,  lost  consciousness,  and  stopped  breath- 
ing ;  extreme  pallor,  dilated  pupils,  cold  sweat,  trismus, 
slight  foaming  at  the  mouth,  urine  passed  into  the  bed. 
With  artificial  respiration,  she  revived  in  half  an  hour, 
and  knew  nothing  of  what  had  happened.  The  empyema 
healed  in  due  course. 

6.  A  man,  with  empyema  of  the  right  side,  was  treated 
(1867)  by  puncture  and  counter-puncture  with  drainage  and 
irrigation  with  plain  water.  On  the  twenty-fourth  day  he 
complained,  for  the  first  time,  that  the  irrigation  was  painful, 
turned  pale,  and  fell  back,  and  for  about  a  minute  there  was 
no  sign  of  pulse  or  respiration ;  then  came  convulsive 
movements  of  the  limbs,  foaming  at  the  mouth,  trismus, 
opisthotonos,  frightful  turgescence  of  the  face,  and  enormous 
thrombi  formed  in  both  upper  eyelids  ;  absolute  loss  of  con- 
sciousness, involuntary  evacuation  ;    then  stertor  and  coma, 


AFTER    THE    OPERATION.  263 

lasting  about  an  hour,  followed  by  loss  of  power  in  the  right 
ann,  which  lasted  only  a  few  days. 

7.  A  boy,  aged  11,  with  empyema  of  the  left  side,  was 
treated  (1871)  by  incision  and  irrigation  with  warm  water  ; 
the  water  luas  th?'0'w?t  into  the  chest  with  ati  enevia-pump. 
On  the  sixth  day  some  violence  was  tised  in  irrigatioii,  and 
the  boy  lost  consciousness,  stopped  breathing,  and  was  con- 
vulsed ;  cyanosis,  trismus,  involuntary  evacuation  ;  he 
remained  unconscious,  with  Cheyne- Stokes  respiration,  and 
died  that  evening,  with  temp.  104". 

It  would  be  easy  to  add  to  these  cases,  but  the  picture 
would  be  no  clearer.  We  may  admit  that  in  this  or  that 
case  the  convulsions  after  irrigation  may  have  been  due 
to  cerebral  embolism,  or  may  have  occurred  in  a  patient 
subject  to  epileptic  fits.  But  there  remain  many  cases 
where  syncope,  convulsions,  transient  paralysis,  or  some 
combination  of  these,  is  due  to  irrigation,  and  to  it  alone. 
The  patients  are  not  epileptics  :  if  they  die,  their  death  is 
not  like  epilepsy,  and  the  most  careful  post  mortem . 
examination  fails  to  show  the  slightest  sign  of  cerebral 
embolism. 

The  patient  may  be  of  either  sex  and  of  any  age  ;  the 
empyema  may  be  of  either  side.  Though  I  have  spoken 
only  of  irrigation,  in  two  cases  syncope  followed  the 
probing  of  a  sinus,  and  the  attempt  to  put  back  a 
tube  that  had  been  left  out.  In  several  instances,  where 
the  surgeon  repeated  the  irrigation  in  spite  of  the  warning, 
the  syncope  or  convulsions  were  also  repeated.  Six  or 
seven  deaths  have  been  recorded,  and  probably  a  much 
larger  number  have  been  left  unpublished.  And  the  two 
facts  to  be  noted  above  everything  else  are  that  the 
patient  has  complained  of  pain,  and  that  the  irrigation 
has  been  done  roughly.  In  those  cases,  therefore,  where 
we  must,  from  the  character  of  the  fluid,  use  irrigation, 
we  must  do  it  very  gently,  being  especially  careful  not  to 
cause  pain  or  to  use  even  the  least  force.     But  in  all 


264  SURGERY    OF    THE    CHEST. 

ordinary  cases  of  empyema  I  endeavour  to  avoid 
altogether  the  need  of  irrigation,  by  early  operation  and 
free  drainage. 

Troubles  arising  from  the  Tube. 

Some  of  these  have  already  been  mentioned — caries 
of  the  rib,  pressure  on  the  diaphragm,  retention  of  masses 
of  fibrin,  haemorrhage  from  the  wound.  Even  the  lung 
may  suffer  harm,  as  in  the  following  case  '  : — 

A  man,  aged  33,  was  admitted  to  Hospital  with  gangrene  at 
the  base  of  the  left  lung.  On  May  i8th,  1889,  a  piece  of  the 
eighth  rib  was  resected  just  outside  the  erector  spinae,  the 
cavity  was  opened,  irrigated,  and  drained.  June  2nd,  slight 
haemoptysis,  and  bleeding  from  the  wound,  from  the  touching 
of  a  tender  spot  during  introduclion  of  the  tube.  June  25th, 
during  the  night,  a  severe  haemoptysis,  of  nearly  half  a  pint  ; 
there  was  also  some  bleeding  from  the  wound.  Next  day, 
the  haemoptysis  returned,  and  was  even  more  severe  ;  and 
next  day  it  suddenly  was  so  profuse  that  the  patient  died. 
The  post  mortem  examination  showed  that  the  cavity  was 
nearly  healed  ;  a  careful  search  did  not  reveal  the  seat  of  the 
haemorrhage.  'It  is  greatly  to  be  regretted  that  the 
drainage-tube  was  not  removed  when  the  irritation  began  ; 
it  seems  almost  certain  that  the  hsemoptysis  was  brought 
about  by  the  tube  causing  ulceration  of  a  vessel.' 

A  far  more  common  trouble  is  the  loss  of  an  ill-shaped, 
badly  secured  tube  within  the  cavity ;  in  one  instance, 
tube  and  safety-pin  were  both  lost  together. 

Those  accidents  in  surgery  which  are  due  to  the  care- 
lessness of  the  surgeon  are  seldom  recorded ;  and  the 
loss  of  a  drainage-tube  inside  the  chest  is  probably  no 
exception  to  this  rule.  The  following  references  may 
therefore  be  worthy  of  note,"  especially  as  they  seem  to 

'  Reported  by  Dr.  H.  Symonds,  "  St.  Bart.  Hosp.  Reports," 
1889,  vol.  XXV.,  p.  249. 

-  For  further  references,  see  Bouveret,  p.  239  ;  and  White  and 
Wood,  "Treatment  of  Empyema,"  Detroit,  1894, 


AFTER    THE    OPERATION.  265 

show  that  there  is  still  some  uncertainty  as  to  the  right 
treatment  in  cases  where  this  dangerous  accident  has 
occurred.  In  two  patients  under  my  care  in  Hospital 
some  years  ago,  I  found  and  removed  the  tube  in  a  few 
seconds  with  a  long  slender  urethral  forceps  :  no  other 
instrument  combines  such  wide  grasp  for  exploring  a 
cavity  with  such  a  slender  shaft  for  passing  through  a 
narrow  sinus. 

M.  Duboue'  has  recorded  a  case  where  the  tube  was 
drawn  in  during  a  deep  inspiration,  and  lost  in  the  cavity  of 
a  chronic  empyema  which  had  been  incised  six  years  before, 
and  had  never  healed.  His  plan  was  to  fish  for  it  daily  with 
a  loop  ot  thin  elastic  cord  ;  his  patience  was  not  rewarded 
till  the  fifteenth  day,  after  nearly  thirty  failures. 

Dr.  de  Havilland  HalP  refers  to  a  case  known  to  him 
of  a  patient  '  in  whose  chest  there  were  about  twelve  inches 
of  drainage-tubing,  owing  to  the  ends  having  been  insecurely 
fastened  together  ;  but  no  ill-effect  had  resulted,  though  the 
tube  had  not  been  recovered.'  He  quotes  two  other  cases  : 
in  one,  about  six  or  eight  inches  of  drainage-tube  had  been 
lost  inside  the  chest  ;  in  the  other,  part  of  a  gum-elastic 
catheter.  '  In  neither  case  were  any  signs  of  the  presence  of 
a  foreign  body  in  the  thorax  exhibited.' 

Mr.  Arthur  Durham  ^  has  recorded  the  case  of  a  youth, 
aged  19,  suffering  from  empyema,  having  a  sinus  kept  open 
with  a  plug  of  lint  soaked  in  carbolised  oil.  One  night 
the  plug  was  drawn  into  the  pleural  cavity  during  violent 
inspiration.  The  patient  said  that  he  felt  it  'go  right  flop 
down  on  his  heart,'  and  next  morning  he  said  that  he  felt  it 
'  close  to  his  spine.'  Mr.  Durham  explored  the  cavity  with 
an  cesophageal  forceps,  felt  the  plug  far  back  in  the  cavity, 
and  seized  and  withdrew  it  without  difficulty. 

Mr.  Brudenell  Carter''  has  noted  the  case  of  a  girl,  aged  17, 
who,  after  being  shot  in  the  chest,  had  htemothorax,  followed 
by  empyema,  which  was  incised  ;  during  delirium,  the 
drainage-tube  fell  or  was  drawn  into  the  pleural  cavity.  This 
was  not  removed,  but  another  tube  was  inserted,  and  worn 

'  "  See.  de  Chir.,"  Paris,  1882,  vol.  viii.,  p.  571. 

=  "  St.  Bart.  Hosp.  Reports,"   1876,  vol.  xii.,  p.  63. 

3  "Lancet,"  1873,  vol.  ii.,  p.  739. 

■*  "  Lancet,"  loc.  cit. 


266  SURGERY    OF    THE    CHEST. 

for  two  years.  It  was  '■hen  left  out,  but  the  fluid  re-collected, 
and  it  was  necessary  again  to  insert  a  tube  ;  and  this  she 
was  still  wearing  at  the  time  when  her  case  was  reported, 
seven  years  after  the  first  tube  had  slipped  into  the  cavity. 
She  was  in  good  health,  and  hard  at  work,  and  had  no 
trouble  from  the  foreign  body. 

Dr.  Symes  Thompson '  has  recorded  a  case  in  which  a 
piece  of  gum-elastic  catheter,  seven  inches  long,  slipped  into 
the  cavity  of  an  empyema,  and  'remained  without  exhibiting 
any  signs  of  its  presence  till  the  death  of  the  patient,  seven 
months  after,  from  exhaustion.' 

Breschet"  gives  a  case  where  a  cannula  fell  into  the  chest, 
and  could  not  be  found.  A  year  later,  '  the  patient  did  not 
suffer  much  from  it,  but  the  discharge  was  more  profuse 
than  it  had  been  before  the  accident.' 

Dupuy  3  had  a  case  of  empyema  of  the  right  side  of  the 
chest,  where  the  tube  fell  into  the  cavity  He  dilated  the 
sinus  with  a  tent,  and  removed  the  tube,  after  some  trouble, 
with  long  curved  forceps.  Some  time  afterward  the  patient 
came  back  to  the  Hospital  ;  the  tube  had  fallen  in  a  second 
time.  Dupuy  tried  in  vain  to  reach  it  with  a  dressing- 
forceps  ;  he  then  turned  the  patient  over,  so  that  the  sinus 
was  undermost,  and  at  once  found  and  removed  the  tube. 

Herard  '■  refers  to  two  cases.  In  one,  a  piece  of  gum- 
elastic  bougie  slipped  into  the  cavity  during  the  night.  It 
was  removed  through  an  incision  made  in  the  third  inter- 
costal space.  In  the  other  case,  a  child,  the  bougie  was  re- 
moved with  a  curved  laryngeal  forceps. 

Abbe  5  has  published  the  case  of  a  boy,  5  years  old, 
having  an  empyema  of  the  left  side,  which  was  opened  with 
a  free  incision.  Six  weeks  after  the  operation  the  drainage- 
tube  slipped  into  the  cavity.  '  The  mother  had  frequently 
noticed  that  on  coughing  or  deep  breathing  the  tube  was 
sucked  in  or  pushed  out  a  couple  of  inches.'  The  child  now 
began  to  have  a  constant  cough.  The  sinus  became 
narrowed,  pus  was  retained,  and  hectic  fever  set  in.  Ether 
was  given,  and,  as  nothing  could  be  felt  with  a  probe, 
the  sinus  was  dilated,  and  different  form.s  of  forceps  were 

'  "  Lancet,"  loc.  cit. 

^  "  Diet.  Encyclop.,"  Art.  "  Corps  Etrangers." 
3  "  Des   soins  a  donner  aux  operes  d'Empyeme."     These  de 
Paris,  1873. 

"  "  Bull,  de  I'Acad.  de  Med.,"  1872,  p.  479. 
5  "  Medical  Record,"  New  York,  Jan.  1882. 


AFTER    THE    OPERATION.  267 

used,  but  with  no  result.  An  inch  of  the  ninth  rib  was 
therefore  excised  close  to  the  sinus,  and  with  the  finger 
the  tube  was  found  lying  far  back  in  the  cavity,  parallel 
to  the  spine.  It  was  easily  removed  with  a  bent  probe  and 
forceps,  and  a  quantity  of  fetid  pus  and  blood  clot  was  let 
out.  The  tube  was  seven  inches  long.  The  child  made 
a  good  recovery. 

Toussaint '  relates  a  very  interesting  case  of  a  man, 
aged  22,  with  empyema  of  the  left  side,  whose  drainage-tube, 
the  size  of  a  20  French  catheter,  fell  into  the  cavity  on  the  ist 
of  July.  It  could  neither  be  felt  with  the  finger  nor  grasped 
with  the  forceps.  Next  day,  the  wound  having  been  dilated 
with  a  sponge  tent,  the  forceps  was  tried  again  :  the  wound 
was  opened  up;  the  patient  was  turned  over;  the  cavity 
was  washed  out  ;  a  long  curved  forceps  was  used.  It  was  all 
in  vain,  and  the  patient  was  so  weak  that  nothing  more 
could  be  done.  A  few  days  later  he  was  found  to  be  suffering 
from  empyema  of  the  opposite  side  of  the  chest  ;  this  was 
repeatedly  punctured,  but  exhaustion,  emaciation,  and  hectic 
fever  led  to  his  death  on  the  17th  of  November,  nearly  four 
months  after  the  tube  had  fallen  into  the  left  pleural  cavity. 
At  the  pos^  mortem  examination,  the  tube  was  found  twisted 
round  a  thick  band  of  adhesions  just  below  the  wound.  One 
end  lay  parallel  to  the  sixth  rib,  and  was  embedded  in  old 
adhesions  ;  the  other  end  was  lodged  in  a  depression  on  the 
surface  of  the  lung. 

Tulpius-  mentions  a  curious  case  of  a  wound  of  the 
thorax,  which  had  been  kept  open  with  a  tent.  This  slipped 
into  the  pleural  cavity  ;  six  months  later  it  was  coughed  up 
into  the  mouth.     The  patient  recovered. 

Lagrange  3  has  published  a  case  where  a  cannula  was 
lost  in  the  pleural  cavity.  'A  probe  passed  into  the  chest 
gave  the  sensation  of  touching  a  foreign  body.  As  the 
patient  would  not  allow  us  to  make  a  free  incision,  we  tried 
dilating  the  sinus  with  a  sponge  tent.  From  the  time  of  the 
accident,  his  general  health  became  worse.'  He  died  of 
phthisis  ;  but  no  mention  is  made  of  the  cannula  in  the 
account  oixhepost  mortem  examination. 

I  "  Sur  las  corps  etrangers  tombes  accidentellement  dans  la 
cavite  pleurale  des  operes  d'empyeme."  "  Rec.  des  Mem.  de 
Med.,"  vol.  iii.,  pp.  37,  567.     Paris,  1881. 

=^Vol.  ii.,  chap.  15. 

3  '<  These  de  Paris." 


268  SURGERY    OF    THE    CHEST. 

Many  of  these  instances  date  from  a  time  when  the 
treatment  of  empyema  was  very  imperfect.  A  large  tube, 
properly  fastened  in  the  wound,  or  furnished  with  a  broad 
shield,  cannot  slip  into  the  pleural  cavity  so  easily  as 
a  small  cannula  or  a  piece  of  catheter.  But  since  this 
disaster  does  still  sometimes  happen,  it  may  be  worth 
while  to  note  what  is  to  be  learned  from  this  list  of  cases. 
They  show  first  that  the  drainage-tube  does  not  drop 
into  the  pleural  cavity,  but  is  sucked  into  it  during 
inspiration  ;  next,  that  it  must  on  no  account  be  allowed 
to  remain  there.  The  cases  published  by  Abbe, 
Toussaint,  and  Lagrange,  and  others  beside  these,  are 
clear  on  this  point.  There  is  no  evidence  that  it  becomes 
covered  by  adhesions;  in  Toussaint's  case,  it  had  been  in 
the  cavity  for  140  days,  and  was  still  loose  in  it.  Next, 
no  time  should  be  lost  before  attempting  its  removal ;  for 
a  fit  of  coughing  may  further  displace  it,  and  carry  it  out 
of  reach.  Next,  if  the  tube  falls  into  the  cavity  soon  after 
the  operation,  before  adhesions  have  formed  round  the 
wound,  it  finds  its  way  downward  and  backward,  and 
tends  to  lie  up  against  the  spine ;  but  if  there  are 
adhesions  round  the  wound,  as  in  Toussaint's  case,  it 
may  get  entangled  in  these,  and  lie  just  below  the 
opening  into  the  cavity. 

It  is  best,  therefore,  having  anaesthetized  the  patient, ^ 
and  placed  him  so  that  the  wound  is  lowermost,  first  to 
explore  just  inside  the  opening,  with  an  oesophageal  or 
laryngeal  forceps.  If  this  fails,  the  whole  cavity  should 
be  explored  with  a  urethral  or  oesophageal  forceps,  and 
afterward  with  the  finger;  and  irrigation  may  be  com- 
bined with  exploration  ;    indeed,  it  has  been  suggested 


'  Or  a  gentle  trial  of  the  forceps  may  first  be  made  without 

any  anassthetic. 


AFTER    THE    OPERATION.  269 

that  irrigation  alone  might  succeed  in  floating  the  tube 
into  the  neighbourhood  of  the  wound  ;  but  if  this  also 
fails,  then  a  free  resection  of  one  or  more  ribs  must 
be  made,  and  the  tube  must  be  sought  at  the  lower  and 
back  part  of  the  cavity,  in  the  neighbourhood  of  the 
vertebrae. 


I  have  now  gone  over  the  chief  risks  and  difficulties 
that  may  arise  after  the  operation  for  empyema,  either 
from  the  general  condition  of  the  patient,  or  from  his 
wound,  or  from  the  cavity  itself,  or  from  the  drainage- 
tube.  Of  my  own  cases,  I  have  quoted  only  those  few 
where  these  risks  and  difficulties  occurred :  there  is 
nothing  to  be  gained  by  printing  those  that  ran  a  smooth, 
uneventful  course  to  recovery. 


270 


CHAPTER  XVIII. 

FISTULA.     CHRONIC  EMPYEMA.     ESTLANDER'S  AND 
SCHEDE'S  OPERATIONS. 

Finally,  we  come  to  those  cases  of  empyema  that 
remain  unhealed  after  operation :  and  must  first  note 
some  practical  points  as  to  the  manner  in  which  an 
empyema  becomes  healed.  The  average  time  of  heaUng 
is  put  by  Runeberg,  from  a  study  of  46  cases,  at  forty-eight 
days  :  Bouveret,  from  61  cases,  puts  it  at  forty-nine  days, 
but  21  of  these  healed  in  less  than  a  month  :  out  of 
Glaser's  20  cases  that  recovered,  15  healed  'in  less  than 
three  months':  Briinnicke  had  3  cases  that  healed  in 
ten,  sixteen,  and  twenty-two  days.  But  averages  are  of 
very  little  value  :  those  of  my  cases  that  ran  a  smooth 
course  healed  in  three  or  four  weeks,  but  one  might  as 
well  attempt  to  strike  an  average  in  typhoid  or  rheumatic 
fever.  The  important  fact  is  that  the  period  is  short  or 
long,  according  as  the  operation  is,  or  is  not,  done  early 
and  with  strict  precautions  against  infection  of  the  cavity. 
Bouveret  found  that  the  average  was  29  days,  if  the 
operation  was  done  in  the  first  month  of  the  disease; 
54,  if  done  in  the  second  month  ;  and  72,  if  done  in  or 
after  the  third  month.  Thus  the  time,  with  an  ordinary 
empyema,  depends  more  on  the  surgeon  than  on  the 
patient. 

As  to  the  method  of  healing,  there  are  many  causes  at 
work  together :  but  for  them  to  combine  toward  rapid 
recovery  of  the  patient,  the  operation  must  be  performed 
early,   and   after   a  right   method,   and   the   lung   must 


FISTULA.      CHRONIC    EMPYEMA.  271 

Still  be  capable  of  expansion.  Roser's  theory,  that 
healing  takes  place  'from  the  bottom,'  by  growth  of 
scar  tissue  beneath  and  around  the  cavity,  starting  some- 
where near  the  root  of  the  lung,  is  by  itself  wholly 
inadequate.  The  formation  of  adhesions,  around  and 
inside  the  cavity,  is  the  chief  cause  of  its  obliteration  ; 
but  for  this,  the  lung  must  expand,  and  for  the  lung 
to  expand,  the  dressing  must  be  so  arranged  that  air  may 
pass  into  it  from  the  cavity  when  the  patient  coughs, 
but  may  not  pass  through  it  into  the  cavity  when  he 
draws  a  deep  breath. 

'  Suppose  that  for  any  reason,  such  as  malignant  disease 
of  the  ribs,  one  has  to  resect  a  large  portion  of  the  chest- 
wall,  what  happens  ?  The  pleura  is  opened ;  the  air 
pours  into  it ;  the  lung  collapses  in  a  heap.  But  is  it 
hopelessly  collapsed ;  is  it  wholly  beyond  the  help  of  the 
movements  of  respiration?  No,  with  each  inspiration 
it  becomes,  if  possible,  more  collapsed,  because  the 
expansion  of  the  opposite  lung  draws  the  last  remnants 
of  air  out  of  it  :  but  with  each  expiration  a  little  air 
enters  by  overflow  from  the  opposite  lung.  Now  comes 
a  fit  of  coughing,  and  behold  the  lung  that  was  collapsed 
now  fills  the  whole  pleura,  and  may  even  become 
prolapsed  or  incarcerated  in  the  wound.  You  cover 
the  wound  with  a  piece  of  protective,  and  apply  a 
deep,  elastic,  fairly  air-tight  dressing — and  next  day,  to 
your  surprise,  you  find  the  lung  safe  back  in  its  proper 
place,  moored  by  adhesions,  and  following  each  move- 
ment of  respiration.  All  the  evils  that  have  been 
imagmed  from  free  admission  of  air  into  the  pleura — 
hopeless  collapse  of  the  lung,  contraction  of  the  chest, 
distortion  of  the  spine — these  things  simply  do  not 
exist,  or,  if  they  do,  they  may  easily  be  avoided  with  a 
proper  antiseptic  dressing.'  (Schede.)     Here  we  have  the 


272  SURGERY    OF    THE    CHEST. 

whole  secret  of  the  healing  of  empyema :  an  early 
operation,  a  lung  still  able  to  expand,  and  the  advantages 
of  coughing,  and  of  a  sort  of  valvular  working  of  the 
dressings,  on  the  side  of  expansion. 

Hence  it  is  evident  that  the  tube  must  not  be  longer 
than  is  necessary.  It  must  be  frequently  cleansed,  and, 
as  the  days  go  on,  it  should  be  changed  for  one  of  smaller 
calibre.  The  change  of  the  discharge,  from  purulent  and 
profuse,  to  serous  and  of  small  quantity ;  the  evidence 
of  physical  signs,  and  of  the  probe,  that  the  cavity  is 
nearly  closed  ;  the  pushing  out  of  the  tube,  not  by  cough, 
but  by  the  advance  of  the  granulations — these  show  that 
it  may  safely  be  left  out.  But  one  may  leave  it  out  too 
soon,  and  be  compelled  to  replace  it.^  In  one  reported 
case,  the  surgeon  made  three  successive  attempts,  from 
the  twelfth  day  onward,  to  do  without  it,  but  each  time 
there  was  a  fresh  access  of  fever,  and  he  had  to  leave  it 
in  to  the  thirtieth  day. 

The  healing  of  an  empyema  may  be  attended  by  some 
deformity  of  the  chest,  or  curvature  of  the  spine.  Our 
surest  way  to  avoid  these  deformities  is  to  operate  early, 
and  to  keep  the  cavity  aseptic.  Happily,  they  are  not 
common  :  there  may  be  a  shght  circumscribed  harmless 
shrinking  of  some  part  only  of  the  chest-wall,  giving 
no  trouble  and  needing  no  treatment ;  but  a  general 
falling-in  of  the  chest-  is  very  rare.     I  do  not  remember 

1  In  24  cases  (Bouveret)  which  ran  a  fairly  smooth  course  to 
recovery,  the  tube  was  left  out,  on  an  average,  at  the  end  of  the 
fourth  week.  In  nine  of  these,  it  was  left  out  before  the  end  of 
the  third  week.  Of  course  there  is  no  rule  :  in  one  of  my  cases, 
a  huge  empyema,  the  tube  was  left  out  on  the  third  day,  and  all 
went  well.  Cases  of  empyema  from  gunshot  wound  involving 
the  lung,  or  from  perforating  disease  of  the  lung,  and  those  that 
have  already  broken  inward,  will  need  longer  drainage,  or  packing 
with  gauze. 

^  The  best  account  that  I  know  of  it  is  Frantzel's,  in  "  Ziems- 
sen's  Handbuch." 


FISTULA.      CHRONIC    EMPYEMA.  273 

to  have  seen  it  in  any  of  my  cases.  Walshe  says  it 
occurs  in  one  out  of  every  twelve  or  fifteen  :  but  the 
percentage  is  probably  now  much  less  than  that.  The 
progress  of  this  general  '  retrecissement  thoracique '  is 
usually  very  slow,  and  may  go  on  for  two  years  or  more. 
The  final  loss  of  size  of  the  affected  side  is  usually  from 
I  to  2  inches,  but  a  case  has  been  recorded  where  3! 
inches  were  lost.  The  ribs  may  almost  or  quite  touch 
one  another,  or  may  overlap  like  the  tiles  of  a  roof :  their 
outer  surfaces  face  somewhat  downward,  their  angle 
with  the  spine  is  narrowed  :  they  move  hardly,  or  not 
at  all,  in  respiration  :  the  shoulder  droops,  the  scapula  is 
projected  outward,  the  lower  border  of  the  chest-wall  is 
brought  close  to  the  crest  of  the  ilium.  There  is  no  con- 
stant relation  between  falling  in  of  the  ribs  and  curvature 
of  the  spine — the  former  may  happen  without  the  latter; 
if  the  spine  be  curved,  the  convexity  of  the  curve  is 
usually,  but  not  always,  toward  the  sound  side ;  compen- 
satory curves  are  often  absent,  and  seldom  clearly  marked. 
Hofmokl's  cases  show  plainly  the  rarity  of  curvature 
of  the  spine  after  empyema.  Out  of  28  cases,  there 
was  marked  curvature  in  i  only ;  this  was  a  child 
six  years  old,  with  pointing  empyema,  treated  by  in- 
cision without  resection,  and  leaving  a  fistula.  In 
17,  it  is  expressly  noted  that  there  was  no  curvature; 
in  the  remaining  10,  there  was  none,  so  far  as  is 
known. 

Such  are  the  chief  points  in  the  healing  of  an 
empyema  after  operation,  and  in  the  troubles  that  may 
attend  or  follow  it.  Prevention  of  these  is  truly  better 
than  cure,  and  they  may  most  surely  be  prevented  by 
early,  skilful,  and  strictly  antiseptic  operation;  by  good 
food,  wine,  fresh  air,  sunshine,  and  prolonged  rest : 
and,  in   some   cases,  by   special   treatment   to   forward 

18 


274  SURGERY    OF    THE    CHEST. 

the  full  expansion  of  the  lung,  and  to  exercise  the  crippled 
side  of  the  chest.^ 

We  have  now  to  consider  what  is  the  treatment  of  an 
empyema  that  does  not  heal  after  operation,  and  will 
not  heal,  and  continues  month  after  month  to  bring  the 
patient  nearer  death  from  exhaustion  or  amyloid  disease. 
Cases  of  non-healing  empyema,  or  rather  of  pyo-pneu- 
mothorax,  due  to  tubercular  disease  of  the  lung  opening 
into  the  pleura,  come  into  the  chapter  on  'Tubercular 
Phthisis :'  at  present,  we  have  to  consider  chronic  fistulous 
empyema,  without  phthisis. 

The  reasons  why  an  empyema  may  fail  to  heal  are,  for 
the  most  part,  to  be  found  in  the  presence  of  conditions 
exactly  the  reverse  of  those  which  promote  rapid  healing. 
They  may  be  illustrated  by  the  following  cases  • : — 

1.  A  farmer,  aged  46,  was  admitted  to  Hospital  in  June, 
1890.  Four  years  ago  he  had  suffered  an  illness  with  acute 
pain  in  the  left  side,  palpitation  of  the  heart,  and  great  weak- 
ness, and  had  taken  no  advice  for  it.  Two  years  ago,  a 
swelling  appeared  below  the  left  nipple,  and  this  hepou/ticed 
till  at  last  it  broke,  and  about  a  quart  of  matter  came  away. 
The  discharge  continued,  in  varying  quantity,  for  about  a 
year  ;  then  the  sinus  closed  for  ten  weeks.  Then  it  opened 
again,  and  a  profuse,  thin,  sanious  discharge  went  on  to  the 
time  of  the  operation. 

2.  A  man,  aged  49,  was  admitted  to  Hospital  in 
September,  1890.  In  January,  he  bad  suff'ered  'pleurisy' 
of  the  left  side,  with  abiding  pain,  which  was  relieved  with 
blisters.     In  February,  a  swelling  appeared  below  the  left 

'  Of  these  '  breath-gymnastics,'  athmcn  gymnastik,  the  chief  are 
the  use  of  some  method  of  forced  expiration,  such  as  blowing 
water  through  tubes  from  one  bottle  into  another— Wolff's 
bottles — and  the  sending  away  of  the  patient  into  mountain  air, 
such  as  that  of  Davos.  It  must  be  remembered  that  some 
slight  pain  is  occasionally  felt  by  patients  when  they  first  enter 
these  regions  of  thin  air. 

^  Sir  William  Stokes,  on  "The  Thoracoplastic  Operation," 
Dublin,  1893.  Meacham,  "A  Synopsis  of  Clinical  Surgery," 
Salt  Lake  City,  Utah,  1893. 


FISTULA.      CHRONIC   EMPYEMA.  275 

nipple,  and  wa.?,  poulticed  for  six  weeks ;  and  he  was  at  this 
time  coughing  up  pus  through  the  mouth.  About  May,  the 
svveUing  waiSpiaicttired,  and  '  about  five  pints'  ot  matter  were 
let  out.  After  this,  poultices  and  irrigations  were  used  up 
to  the  time  of  the  operation. 

3.  A  miner,  aged  30,  had  suffered  fracture  of  two  right 
ribs,  7!i7ie  years  ago,  and  a  few  months  later  had  pneumonia 
of  that  side,  with  effusion.  Six  months  later,  a  quart  of  pus 
was  removed  with  the  aspirator ;  and  this  nietJiod  of  treatment 
was  used  again  and  again.  Not  till  six  years  had  passed, 
was  a  piece  of  one  rib  resected.  A  year  later,  he  was  cured 
by  free  resection. 

One  might  add  a  score  of  cases  to  show  that  an  un- 
healed empyema  is,  as  a  rule,  the  direct  result  of  the 
patient's  neglect,  or  of  the  surgeon's  delay,  or  of  in- 
adequate and  useless  surgery:  but  our  business  now  is 
to  enquire  how  we  may  most  surely  and  safely  cure  it. 
There  is,  of  course,  no  one  kind  of  chronic  empyema: 
the  patient  may  be  young  or  old,  in  good  health  or 
exhausted,  or  already  affected  with  amyloid  disease. 
There  may  be  only  a  short  sinus  leading  to  a  small 
cavity,  or  there  may  be  a  huge  pneumothorax,  a  mere 
remnant  of  lung,  and  an  enormously  thickened  pleura 
of  almost  cartilaginous  hardness.  And  as  there  is 
no  clear  picture  of  chronic  empyema,  so  there  is  no  one 
formal  operation  for  its  cure  :  the  treatment  ranges  from 
the  resection  of  two  small  pieces  of  rib,  and  the  scraping 
of  a  sinus,  to  the  most  severe  form  of  '  thorax- 
resection.'  With  all  these  operations,  two  names  are 
chiefly  associated — those  of  Estlander  ^  and  Schede. 
The  term,  '  Estlander's  operation,'  is  very  loosely  used  : 
nor  was  he  the  first  to  do  free  resection  in  these  cases. 
His  operation,  as  Schede  says  of  it,  was  '  in  the  air,'  and 
had  already  been  done  a  few  times,  at  places  far  apart. 

'  "  Revue  Mensuelle,"  1879.  The  same  operatiori  had  been 
done  already  by  Gayet  and  Letievant,  in  France;  and  by  Kiister 
and  Schede,  in  Germany. 


276  SURGERY    OF    THE    CHEST. 

He  did  not  invent  a  wholly  new  thing,  but  his  work  is 
hardly  less  valuable  on  that  account.  The  method  of 
turning  up  a  single  large  flap  of  skin  and  muscle  came 
later,  and  Schede's  principal  contribution  to  the  surgery 
of  the  subject  is  his  observation  that  in  certain  very 
bad  cases  the  pleura  must  be  removed  to  the  same 
extent  as  the  ribs. 

Each  case  must  be  taken  on  its  own  merits  :  an 
operation  that  might  be  necessary  for  a  man  might  be 
wholly  unjustifiable  on  a  child.  The  size  and  age  of  the 
cavity,  the  health  and  previous  habits  of  the  patient,  the 
exact  character  of  the  operation  or  operations  already 
performed — all  these  must  be  taken  into  account.  The 
size  of  the  cavity  may  be  estimated  by  the  physical  signs 
on  auscultation  and  percussion,  the  use  of  the  probe, 
and  the  amount  of  the  discharge.  The  smaller  the  cavity, 
and  the  younger  the  patient,  so  much  more  hope  is  there 
that  a  limited  resection  may  suffice ;  and  this  may  with 
advantage  in  some  cases  be  combined  with  loose  packing 
of  the  cavity  with  gauze.  But  a  huge  cavity,  rigid  ribs,  a 
lung  past  all  possibility  of  expansion,  an  enormously 
thickened  pleura,  all  these  may  combine,  in  a  patient 
advanced  in  years,  to  produce  a  condition  that  can 
only  be  cured  by  an  operation  of  very  great  severity. 
Nor  is  there  any  sure  way  of  knowing  the  true  thickness 
of  the  pleura,  save  by  information  obtained  from  some 
earlier  operation  which  failed  just  because  it  left  the 
pleura  instead  of  removing  it. 

Of  all  forms  of  '  Esilander's  operation,'  it  may  be  said 
that,  as  a  general  rule,  the  resection  of  the  ribs  should 
be  subperiosteal,  and  that  the  raising  of  a  single  large 
flap  of  skin  and  soft  tissues  is  better  than  the  use  of 
separate  incisions,  or  of  a  single  large  incision.  In 
theory,  there  is,  of  course,  a  distinction  between  Est- 


FISTULA.     CHRONIC   EMPYEMA.  277 

lander's  operation,  which  is  a  '  plastic '  removal  of  the 
ribs  over  the  whole  length  and  breadth  of  the  cavity, 
and  any  less  thorough  resection  which  aims  not  at 
obliterating  the  cavity  by  atmospheric  pressure,  but  at. 
closing  it  by  freely  opening  and  draining  or  packing  it ; 
but  practically  this  distinction  is  not  strictly  observed. 

We  may  do  well  to  consider  all  sweeping  resections  of 
ribs  as  a  last  desperate  necessity,  a  confession  of  failure. 
There  is  evidence  that  a  long-collapsed  lung  may  yet 
expand  :  its  exact  power  of  endurance  of  collapse  is  not 
known  :  but  at  an  earlier  period  of  surgery,  when  opera- 
tion was  much  delayed  for  various  reasons,  it  was 
supposed  to  be  somewhere  between  two  and  five  months. 
Ewald  had  a  case,  a  woman  70  years  old,  where  a  lung 
expanded  after  six  months  of  compression  (even  after 
fifteen  and  eighteen  months,  expansion  has  occurred);  and 
Slajner  says  he  has  cured  six  cases  of  chronic  empyema, 
with  fistula,  by  Bulau's  method.  We  do  not  really  know 
when  a  chronic  empyema  is  quite  hopeless,  at  all  events 
during  childhood.  The  literature  of  empyema  is  full  of 
cases  which  seemed  to  have  drifted  past  all  hope  of 
moderate  measures,  and  yet  were  cured  by  resections 
less  severe  than  a  thorough  Estlander's  operation,  and 
much  less  severe  than  Schede's  '  thorax-resection.' 

But  we  are  none  the  less  bound  to  admire  the  accuracy 
and  forethought  and  splendid  results  of  Schede's  oper- 
ations. At  this  point,  then,  let  him  take  up  the  story.  I 
give  an  abstract  of  part  of  his  paper  ^  at  the  Medical 
Congress  at  Vienna,  in   1890,  and  of  his  cases. 

'  In  chronic  empyema,  when  the  time  has  been  lost  beyond 
recall,  and  the  lung  can  no  longer  expand,  the  only  hope 
for  the  patient  is  that  the  shrinking  of  the  enormously 
thickened  pleura  may  at  last  bring  the  parts  together  :  for 

'  "  Verhandl.  d.  Congr.  f.  Inn.  Med."  ix.  Wien.,  1890,  p.  41. 


278  SURGERY    OF    THE    CHEST. 

this  to  happen,  the  patient  must  be  young,  with  his  ribs  still 
elastic  and  freely  movable,  and  the  cavity  must  not  involve 
the  whole  side  of  the  chest.  But  with  a  huge  cavity,  in  an 
elderly  patient,  with  rigid  ribs,  and  a  useless  remnant  of  lung, 
what  good  would  it  be  to  remove  even  the  whole  of  every 
rib,  unless  the  costal  cartilages,  the  soft  parts,  and  the  enor- 
mously thickened  plem-a,  were  all  able  to  fall  in?  It  is  only 
in  children  that  they  can  thus  fall  in — they  cannot  in  adulrs. 

For  such  cases  as  these,  Estlander's  operation  is  wholly 
inadequate  :  so  long  ago  as  1877-79,  I  resected,  in  more  than 
one  case  (not  children)  as  many  as  nine  ribs,  even  going  back 
beneath  the  scapula  ;  and  when  this  failed,  I  resected  them 
still  further,  and  once  again  still  further.  I  also  tried  simple 
section  in  two  places,  without  resection,  of  a  large  number  of 
ribs,  but  it  was  all  in  vain  ;  the  enormously  thickened  pleura 
still  refused  to  fall  in.  It  is,  then,  the  pleura  that  you  must 
remove  :  this  I  thought  out  for  myself  in  1878,  and  I  have 
now  (1890)  done  this  operation  ten  times.  On^  patient, 
after  doing  well  at  first,  died  of  Bright's  disease,  and  one  died 
of  iodoform-poisoning ;  all  the  others  recovered,  and  were 
saved  from  certain  death. 

My  method  of  thorax-resection  is  as  follows  :  The  mcision 
starts  at  the  outer  edge  of  the  pectoral  muscle  (which  may 
need  to  be  divided  a  little  way),  about  the  level  of  the  fourth 
rib,  and  is  carried  downward  in  a  curve  to  the  lowest  point 
of  the  pleural  cavity,  z.e.,  the  tenth  rib  in  the  posterior 
axillary  line.  It  is  then  curved  upward,  and  carried  up  along 
the  vertebral  border  of  the  scapula,  this  bone  being  drawn 
out  of  the  way  by  pulling  the  arm  forward  across  the  chest. 
The  mcision  is  everywhere  carried  down  to  the  ribs,  and  then 
the  huge  flap  of  skin,  with  the  scapula  and  the  subscapularis 
muscle,  is  rapidly  cleared  and  raised.  Next  comes  the  sub- 
periosteal resection  of  all  the  ribs  over  the  cavity.  If  the 
cavity  is  nothing  less  than  the  whole  pleura,  it  is  usually 
necessary  to  remove  every  rib,  from  the  second  to  the  ninth, 
or  even  to  the  tenth,  from  the  junction  between  bone  and 
cartilage  in  front,  to  the  tubercle  of  the  rib  behind.  The 
resection  must  be  sub-periosteal,  to  avoid  haemorrhage.  The 
ribs  need  not  be  cleared  further  back  than  a  point  a  little 
beyond  their  angles  ;  then  you  divide  each  rib,  about  the 
niiddle,  with  the  bone-forceps,  draw  the  cut  ends  apart,  and 
bi'eak  them  off;  the  anterior  portion  you  break  off  at  the 
junction  between  bone  and  costal  cartilage,  the  posterior 
portion  you  break  off  near  its  vertebral  attachment  (it  breaks, 
almost  always,  close   to  the  tubercle).     Next,    with  strong 


FISTULA       CHRONIC   EMPYEMA  279 

scissors,  you  cut  away  the  enormously  thickened  pleura  and 
the  intercostal  muscles,  etc.,  over  the  whole  cavity.  In 
almost  every  case  there  is  a  fistulous  opening  through  the 
pleura.  Make  this  your  starting  point,  and,  of  course,  to 
avoid  cutting  the  intercostal  vessels  twice,  you  must  divide 
the  posterior  boundary  of  the  pleura  first.  Each  intercostal 
artery  must  be  compressed,  between  finger  and  thumb,  by 
your  assistant  or  by  yourself,  before  you  divide  it,  and 
ligatured  after  division. 

You  now  have  to  cover  the  great,  flat,  trough-shaped 
cavity  with  your  huge  flap  of  skin  and  muscle.  Your  chief 
difficulty  here  is  with  the  uppermost  part  of  it,  which  it  is, 
as  a  rule,  impossible  to  fill  up  in  a  satisfactory  way  :  and  a 
tedious  fistulous  suppuration  is  likely  to  go  on  here,  till  all 
the  soft  parts  have  finally  fallen  in  ;  and  this  is  a  work  of 
time,  for  here  you  have  left  behind  the  uppermost  zone  of  the 
thickened  pleura.  A  space  thus  left  uncovered  is  very  diffi- 
cult to  heal.  In  one  case,  I  tried  refreshing  it  with  a  knife, 
but  I  cannot  recommend  this  method,  as  you  may  get  almost 
uncontrollable  oozing  from  the  lung  :  nor  do  Thiersch's 
grafts  help  you.  Some  sort  of  plastic  operation  is  necessary. 
Schneider  resected  a  part  of  the  clavicle  ;  De  Cerenville 
resected  a  small  part  of  the  first  rib. 

The  whole  procedure  takes  a  year,  or  longer.  And  this  is 
the  strange  part  of  it,  that  so  soon  as  the  scarring  is  complete, 
and  the  patient  begins  to  use  his  arm  again,  the  lung  begins 
again  to  expand  and  to  act  ;  the  mangled  look  of  the  chest 
begins  to  amend,  the  side  regains  its  shape,  the  lateral 
curvature,  so  frightful  at  first,  disappears  ;  and  at  last, 
when  the  patient  lias  his  clothes  on,  there  is  no  very  marked 
deformity  after  all.' 

I  have  been  careful  to  transcribe  accurately  Schede's 
account  of  his  method.  It  is  certainly  not  an  operation 
that  most  surgeons  would  welcome  if  they  could  honestly 
avoid  it,  nor  would  the  results  of  it,  if  it  were  generally 
practised,  be  such  as  Schede  himself  has  obtained. 
Still,  the  danger  of  it  is  less  than  it  appears  at  first 
sight  :  the  desperate  state  of  the  parts  is  itself  an  advan- 
tage ;  the  lung  is  past  considering,  the  whole  cavity  is 
already  opened  to  the  air  :  one  is  not  really  operating  on 
an  empyema,  but  removing  a  great  cage  or  frame  of  ribs 


28o  SURGERY    OF    THE    CHEST. 

and  thickened  pleura,  beneath  which  there  are  no  struc- 
tures that  one  need  either  respect  or  fear.^ 

Finally,  one  must  study  his  cases  very  carefully.  The 
first  five  are  cases  of  very  extensive  resection,  but  without 
removal  of  the  thickened  pleura  ;  the  last  seven  are  true 
'thorax-resections.'  J^/a^e  VII,  copied  from  his  work, 
shows  the  condition  for  which  he  advocates  this  'thorax- 
resection.'  " 

Five  Cases  of  Extensive  Resection  of  Ribs  for 
Persistent  Empyema. 

I.  Male,  aged  22.  Duration  of  disease  not  known.  Old 
circumscribed  fistulous  empyema,  occupying  lower  part  of 
left  side  of  chest,  at  the  side  and  behind.  The  first  operation 
was  only  resection  of  a  small  piece  of  the  seventh  rib, 
followed  by  drainage.  Business  affairs  obliged  him  to  leave 
the  Hospital.  A  fortnight  later,  no  definite  shrinking  of 
cavity.     Resection  of  sixth  to  tenth  ribs,  6  to  10  cm.  of  each, 

ijn  1892,  at  the  meeting  of  the  British  Medical  Association  at 
Nottingham,  Mr.  Croft  proposed  that  in  some  cases  of  this  kind 
one  might  even  remove  the  remnant  of  the  lung.  'When  an 
enormous  pleural  cavity  is  bounded  on  one  side  by  a  collapsed 
moveable  swinging  dangling  lung,  and  on  the  other  side  by  rigid 
bony  wall,  would  the  removal  of  the  useless  swinging  lung,  at  or 
near  its  root,  be  a  safe  and  useful  measure  ?  I  am  disposed  to 
think  that  its  presence  is  an  obstacle  to  the  cessation  ot  discharge 
from  the  pleura,  and  that  its  removal  would  be  a  step  half-way 
to  cure.  I  am  supposing  that  the  lung  is  useless  as  a  respiratory 
organ,  and  that  adequate  measures  for  its  fixation  have  failed  of 
their  purpose.  The  loss  of  such  a  spoiled  organ  should  prove  to 
be  a  gain.' — "Brit.  Med.  Jour."  1892,  ii,  245. 

But  apart  from  the  difficulty  of  knowing  whether  the  lung  has 
or  has  not  gone  past  hope  of  expansion,  there  is  this  further 
objection  to  Mr.  Croft's  plan,  that  the  remnant  of  lung  may  not 
be  moveable,  swinging,  and  dangling,  but  as  m  Plate  VII,  fixed, 
flattened  and  obliterated. 

^  But  we  cannot  without  reserve  accept  his  assurance  that  after 
operation  the  outUne  of  the  chest  becomes  in  time  greatly 
improved:  his  own  cases,  and  those  published  by  Mr.  Pearce 
Gould  and  Dr.  Meacham,  show  that  we  can  save  the  patient's 
life,  but  only  at  the  risk  of  great  permanent  deformity.  An 
interesting  case  of  the  operation  was  published  by  Mr.  W. 
G.  Spencer  in  the  Transactions  of  the  Clinical  Society  for  1894. 


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FISTULA.     CHRONIC   EMPYEMA.  281 

and  free  incision  of  the  pleura  over  the  whole  extent  of  the 
cavity.     Drainage.     Discharged  cured  in  six  weeks. 

2.  Female,  aged  37.  Large  chronic  fistulous  right  em- 
pyema. Nearly  a  year  ago,  it  had  been  incised  in  the  sixth 
space,  posterior  axillary  line,  and  the  incision  had  never 
healed.  Profuse  discharge  from  fistula  ;  marked  falling-in  of 
chest,  definite  lateral  curvature  of  spine ;  an  immense  cavity. 
Resection  of  fifth  to  eighth  ribs,  from  juncture  with  their  carti- 
lages back  to  their  tubercles  ;  they  were  welded  together 
with  bridges  of  bone,  and  lay  so  close  that  their  intercostal 
spaces  were  quite  obliterated.  The  pleura  had  become  a 
tough  layer  of  tissue,  2  cm.  thick.  Incision  through  the 
pleura  showed  that  the  lung  was  not  wholly  collapsed  ;  its 
surface  was  distant  3  cm.  from  the  chest-wall.  Drainage ; 
irrigation.     Healed  in  seven  months. 

3.  Male,  aged  18.  Relapse  after  typhoid,  followed  by 
pleurisy  and  empyema.  After  repeated  simple  punctures  of 
the  serous  effusion,  Bulau's  drainage  was  begun  in  April,  and 
later  the  cavity  was  repeatedly  irrigated.  June  15th,  Bulau's 
method  left  off;  July  8th,  fistula  closed.  Then  the  patient 
became  feverish,  and  on  August  ist  the  fistula  re-opened, 
and  discharged  a  quantity  of  pus  :  further  drainage  had  no 
result.  Nov.  nth,  fistula  in  sixth  left  space,  anterior  axillary 
line,  leading  into  a  cavity  3  to  5  inches  in  diameter.  Curved 
incision,  convex  downward,  from  edge  of  sternum  to  poste- 
rior axillary  line,  reaching  as  low  as  eighth  rib.  Resection, 
about  9  cm.  each,  of  sixth,  seventh,  and  eighth  ribs  :  they 
overlapped  like  the  tiles  on  a  roof.  Incision  of  the  pleura, 
evacuation  of  the  cavity  :  a  second  enormous  flattened  cavity 
was  now  found,  extending  over  nearly  the  whole  posterior 
aspect  of  the  chest-wall.  It  was  necessary  again  to  resect 
sixth  and  seventh  ribs  right  back  to  their  tubercles,  also  8  cm. 
each  of  the  fourth  and  fifth  ribs  :  altogether  about  80  cm.  of 
ribs  were  removed.  Pleura  laid  open  freely,  huge  cavity 
scraped,  whole  space  loosely  packed  with  iodoform  gauze. 
Later,  irrigation  with  astringent  solutions.  Discharged,  com- 
pletely cured,  April  17th.     Naphthalin  gauze  was  also  used. 

4.  Little  girl,  aged  7.  Large  chronic  left  empyema,  with 
fistula  in  seventh  space  just  outside  nipple  line  :  dulness 
over  whole  side,  except  just  round  fistula:  profuse  discharge, 
slight  retraction  ot  chest- wail.  May  2nd,  the  ribs  so  over- 
lapped that  resection  of  eighth  and  ninth  ribs  only  had  no 
effect.  It  was  necessary  to  resect  all  ribs  from  second  to 
tenth  (about  80  cm.  in  all);  the  walls  of  the  huge  cavity  then 
fell  together.     It  was  packed  with   iodoform  gauze  :  some 


282  SURGERY    OF    THE    CHEST. 

collapse  after  operation  :  on  tenth  day,  slight  iodoform 
poisoning.  The  cavity  quickly  closed,  the  lung  expanded 
completely,  the  deformity  disappeared,  the  ribs  were  re- 
generated.    Discharged,  7  lbs.  heavier,  December  15th. 

5.  Male,  aged  32,  After  pneumonia,  right  empyema 
{?  tuberculous  origin),  which  was  treated  from  April  to  August 
by  aspiration  drainage  without  success.  In  August,  resection 
of  eighth  and  ninth  ribs ;  in  October,  fistula,  flattened  cavit}', 
and  long  sinus  running  up  to  level  of  middle  of  scapula. 
November  2nd,  resection  of  seventh  and  eighth  ribs  (20  cm. 
each)  and  ninth  rib  (16  cm.),  free  incision  of  pleura,  scraping 
of  contents,  mixed  with  flakes  of  pus  and  fibrinous  deposit, 
packing  with  iodotorm  gauze.  Long  sinus  scraped,  irrigated, 
and  drained.  By  January  (in  spite  of  intercurrent  peri- 
typhlitis) cavity  healed,  small  external  fistula  healing. 
Later,  acute  phthisis. 

Seven  Cases  of  'Thorax-Resection.' 

I.  Boy,  aged  9.  Three  years  ago,  pleuropneumonia, 
followed  by  right  empyema,  which  broke  outward,  and  has 
discharged  ever  since.  Very  large  empyema;  fistula  in  sixth 
space,  just  outside  nipple  line  ;  general  condition  very  bad  ; 
advanced  amyloid  disease.  April  :  Resection  of  sixth  rib, 
counter  opening  by  resection  of  tenth  rib  ;  evacuation  ot 
large  quantity  of  fcetid  pus,  irrigation,  thorough  drainage. 
Marked  iiiiprovement  in  general  health.  But  the  pleura 
was  3  cm.  thick,  and  of  almost  cartilaginous  hardness. 
The  size  of  the  cavity  was  not  reduced  ;  the  ribs  had  fallen 
in  a  little,  but  it  was  impossible  they  should  fall  in  enough,  or 
that  the  lung  should  expand  enough — so  it  was  decided  to  do 
thorax  resection,  dy  repeated  opej-ations.  May  20th  :  Long 
curved  incision,  rising  upward  toward  vertebral  border  of 
scapula.  Ribs  so  approximated  that  they  were  in  contact. 
Resection  of  sixth  to  eleventh  ribs,  about  12  cm.  of  each. 
Then  the  rigid  cicatricial  pleura  was  removed  over  the  whole 
extent  of  the  opening.  Intercostal  arteries  compressed  before 
division  ;  bleeding  not  severe.  Cavity  packed  with  gauze. 
Complete  recovery  without  fever.  June  12th:  Soft  parts 
raised  by  an  incision  carried  backward  and  upward  to  spine 
of  scapula  :  scapula  and  subscapularis  thoroughly  freed  to 
an  equal  extent,  arm  drawn  well  forward,  second  to  fifth 
ribs  resected.  Removal  of  thickened  tissues  as  at  previous 
operations  :  skin-flap  applied  to  fill  gap  thus  left.  A  month 
later,  a  plastic  operation  was  needed,  and  for  some  months 


FISTULA.      CHRONIC   EMPYEMA.  283 

there  remained  a  fistula.  By  May  of  next  year,  all  was 
healed  :  two  years  later,  there  was  marked  falling-in  of  chest- 
wall  :  later  still,  there  was  lateral  curvature,  but  not  excessive  : 
considerable  recovery  of  lung;  signs  of  amyloid  disease 
vanished ;  general  condition  very  good  ;  movements  of  arm 
wholly  unhindered. 

2.  Male,  aged  29.  Three  years  ago,  right  empyema :  after 
long  delay,  incised  :  later,  resection  first  of  sixth,  then  of 
seventh  rib.  Now,  general  condition  good  :  very  marked 
falling-in  of  chest-wall:  empyema  cavity  of  considerable 
extent,  holding  50  cub.  cm.  In  the  hope  that  a  complete 
'thorax  resection'  was  unnecessary,  resection  of  fifth  to  eighth 
ribs  only  (5  or  6  cm.  each),  and  free  opening  into  the  cavity, 
followed  by  packing,  astringents,  etc.,  and  compression  of 
chest-wall  with  strappmg.  Only  slight  improvement ;  cavity 
still  30  cub.  cm.  March  31st,  1886:  Resection  of  second, 
third,  fourth,  and  ninth  ribs  (6  to  10  cm.  each),  nearly  up  to 
the  spine;  very  troublesome  hjemorrhage  from  latissimus 
and  other  muscles  ;  ribs  much  thickened  by  osteophytes. 
Total  ablation  of  soft  parts;  scraping  and  packing.  No 
reactionary  fever,  still  cavity  did  not  close.  May  24th, 
Resection  of  seventh  rib  (10  cm.  anterior  end),  and  of 
remnants  of  vertebral  ends  of  eighth  to  tenth  ribs.  Cavity 
covered  by  flaps  taken  from  scapular  and  abdominal  regions. 
June  26th  :  went  home  with  a  fistula.  By  next  spring,  com- 
pletely healed. 

3.  Female,  aged  17  ;  general  condition  very  grave,  and 
so  feeble  that  she  turns  faint  on  sitting  up  in  bed.  Three  years 
ago,  after  severe  pleurisy,  empyema,  neglected  for  four 
months,  then  only  punctured.  Then  continuous  syphon- 
drainage,  no  result.  Then  resection,  freely,  of  several  ribs ; 
but  no  markeddiminution  of  cavity.  Present  general  condition 
as  above  ;  fistula  about  tenth  space,  far  back.  Great 
falling-in  of  chest-wall,  all  the  ribs  touch  ;  enormous  cavity  ; 
absolute  collapse  of  lung.  May  24th  :  Huge  flap  turned  up, 
including  scapula  ;  subperiosteal  resection  of  second  to  tenth 
ribs  in  their  whole  extent  (160  cm.  in  all),  then  removal  of 
soft  parts  with  the  huge  cicatricial  pleura,  at  least  2  cm.  thick: 
loose  packing.  Sent  home  in  five  weeks ;  complete  healing 
(retarded  by  a  fistula)  by  February.  '  Very  striking  in  this 
case  was  the  gradual  disappearance,  after  complete  healing 
of  the  wound,  of  the  curvature,  which  was  at  first  very 
marked  ;  and  at  the  same  time  the  gradual  resumption  of  a 
part  of  its  function  by  the  collapsed  lung.'  The  movement 
of  the  arm  was  in  no  way  hindered. 


284  SURGERY    OF    THE    CHEST. 

4.  Male.  Seven  years'  suffering  from  enormous  empyema 
of  whole  left  side  of  chest.  Punctured  in  third  week;  later, 
on  two  occasions,  extensive  resection,  but  without  any  suc- 
cess. Present  condition :  tall,  pale,  wasted,  wretched. 
Enormous  cavity  (second  to  ninth  ribs),  daily  discharge 
profuse.  July  7th  :  Resection  of  second  to  ninth  ribs  in 
almost  their  whole  extent  (150  cm.) ;  removal  of  soft  parts  ; 
loose  packing  with  iodoform  gauze.  Haemorrhage  not 
severe ;  no  fever.  On  July  loth,  signs  of  iodoform  poisoning, 
and  death  one  week  after  operation. 

5.  Male,  aged  28.  Two  and  a  half  years  ago,  left  pleurisy, 
followed  by  empyema;  two  years  ago,  continuous  syphon- 
drainage.  He  was  kept  in  bed  for  six  months,  and  then  got 
about  with  a  bottle ;  discharge  always  very  profuse.  Present 
condition :  pale,  wasted ;  drainage  track  in  fifth  space, 
between  nipple  and  axillary  lines.  August  29th  :  Large  flap  ; 
exposed  ribs  not  only  touching,  but  so  twisted  that  their 
anterior  surfaces  looked  upward.  Resection  of  fifth,  sixth, 
and  seventh  ribs  (12  cm.  each);  removal  of  soft  parts 
including  pleura,  which  was  as  thick  as  one's  finger,  and  of 
extreme  hardness.  Loose  packing  with  iodoform  gauze. 
He  did  well  for  four  months,  then  signs  of  chronic  nephritis 
set  in;  he  lost  ground,  and  the  discharge  again  became 
profuse.     Discharged  at  own  request  June  23rd. 

6.  Male,  aged  24.  Three  and  a  half  years  ago,  Nov.,  1884, 
empyema,  which  burst  of  itself.  A  month  later,  it  was  incised 
and  drained  ;  drain  fell  into  cavity,  and  could  not  be  found 
till  nine  months  later.  Nov.,  1886:  Resection  of  two  ribs, 
followed  by  irrigation  ;  no  effect.  April,  1887  :  Resection  of 
several  upper  ribs,  in  front  of  chest ;  no  marked  effect. 
April,  1888  :  General  condition  good ;  great  falling-in  of  chest- 
wall,  fistula  fourth  left  space,  anterior  axillary  line,  also  two 
fistulas  in  front.  Very  large  cavity;  almost  entire  collapse 
of  lung  (but  small  areas  in  front  and  behind  where  breath- 
sounds  were  heard).  May  2nd  :  Incision  from  spine  of 
scapula,  down  alongside  its  vertebral  border,  and  curved 
forward  to  eighth  costal  cartilage ;  all  soft  parts  cut  through 
down  to  the  ribs,  and  the  huge  flap,  including  the  scapula 
and  the  subscapularis  muscle,  raised  and  drawn  upward  as 
high  as  possible.  Then  subperiosteal  resection  of  second  to 
eighth  ribs,  from  cartilages  to  tubercles.  Next,  with  scissors, 
the  whole  outer  wall  of  the  cavity — intercostal  muscles, 
periosteum  of  ribs,  and  enormously  thickened  (2  cm.)  rigid 
pleura — was  cut  away.  Bleeding  easily  controlled,  intercostal 
arteries   compressed    between    finger    and    thumb,    before 


FISTULA.     CHRONIC    EMPYEMA.  285 

division,  and  caught  with  forceps.  Iodoform  gauze,  in 
layers,  laid  over  thickened  puhiionary  pleura;  huge  flap  laid 
down  and  drained;  uncovered  area  (hand's-breadth)  left  at 
lower  circumference  of  wound.  Long  delay  in  healing, 
'because  in  this  case,  as  in  others,  the  puhnonary  pleura 
showed  itself  very  incapable  of  producing  healthy  granu- 
lations ' ;  all  sorts  of  applications  used  in  vain.  August  20th : 
Discharged;  large,  granulating  surface  in  axilla,  which  had 
frequently  given  rise  to  slight  bleeding.  Thiersch's  grafts 
had  failed.  Finally,  a  year  after  operation,  a  plastic  operation 
was  done  while  he  was  in  Hospital  again  for  removal  of  a 
tuberculous  kidney.  General  health  very  good  :  marked 
curvature  of  whole  dorsal  spine,  convex  to  left ;  lung  acts 
now  more  or  less  over  its  whole  extent.  He  still  can  hardly 
raise  the  arm  at  all. 

7.  Male,  aged  20.  Three  years  ago,  right  empyema, 
which  burst  of  itself.  Six  months  later,  resection  of  several 
ribs.  Great  falling-in  of  chest-wall  :  three  fistulte  toward 
front  of  chest,  leading  into  an  enormous  cavity.  July  24th, 
1888  :  Thorax  resection  as  in  previous  cases.  Subperiosteal 
resection  of  fourth  to  tenth  ribs,  in  whole  length  from 
cartilage  to  tubercle  :  they  were  found  overlapping,  and 
here  and  there  welded  together  by  bridges  of  bone.  Removal 
of  soft  parts  and  of  greatly  thickened  pleura;  pulmonary 
pleura  scraped,  covered  with  gauze,  flap  replaced.  Bore 
operation  well ;  all  healed  but  the  fistulse,  then  things  came 
to  a  standstill,  and  so  remained  for  months.  June  3rd,  1889: 
Upper  part  of  scar  was  opened  up,  and  cavity  behind  upper 
ribs  exposed.  Dec.  nth:  Resection  of  second  rib  (4cm.), 
and  third  rib  (6  cm.)  in  front,  cavity  here  freely  exposed, 
scraped,  drained  with  counter-opening,  and  packed  with 
gauze.  Complete  recovery,  with  no  marked  lateral  curvature, 
and  good  action  of  lung. 

It  is  evident  that  operations  so  severe  as  these  are 
justified  only  as  a  last  resource,  in  cases  that  have  been 
long  neglected,  or  subjected  to  treatment  so  inadequate 
as  to  be  useless.  They  may  be  compared  to  amputation 
at  the  hip  in  the  last  desperate  stage  of  hip-disease — the 
last  act  of  a  tragedy  that  might  perhaps  have  ended 
differently  if  the  disease  had  been  better  treated  in  its 
earlier  staa:es. 


286 


CHAPTER  XIX. 

ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS. 

We  have  now  come  at  last  to  those  diseases  of  the 
lung  itself  that  may  admit  of  treatment  by  operation  ; 
and,  if  we  look  back  over  the  ground  already  covered,  it 
is  evident  that  this  new  field  of  work  has  been  reached 
by  the  advance,  all  along  the  line,  of  the  whole  aim  and 
method  of  the  surgery  of  the  chest. 

History. 

Thirty  years  ago,  the  pleura  stood  between  the  surgeon 
and  the  lung,  just  as  the  peritoneum  blocked  the  way 
of  abdominal  surgery;  and  so  long  as  the  operations 
on  the  pleura  were  irresolute  and  inadequate,  there  could 
be  no  advancement  of  operative  treatment  of  the  lung. 
Yet  from  time  to  time  there  were  men  ahead  of  their  age. 
Such  were  Baglivus  (1710),  who  treated  a  wound  of  the 
lung  by  free  incision  of  the  pleura,  and  recommended 
the  same  treatment  for  'phthisis  ab  ulcere  pulmonum,' 
and  De  Bligny  (1720)  Barry,  and  Boerhaave,  who,  a 
few  years  later,  advised  free  incision  of  lung  cavi 
ties.  About  1780,  David  recommended  incision  in  cases 
of  simple  abscess,  provided  the  pleura  was  adherent ;  in 
1783,  Pouteau  published  a  case  cured  by  this  treatment; 
and  in  181 2,  Richerand  spoke  of  incision  of  the  lung  as 
if  it  were  now  established  beyond  the  reach  of  criticism, 
and  suggested  the  use  of  exploratory  punctures  in 
doubtful  cases  of  abscess.  In  1818,  Zang  reported 
fifteen  instances  of  incision  of  the  chest-wall,  seven  for 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     287 

empyema,  eight  for  abscess  ;  in  1830,  Krimer  made 
careful  study  of  the  relation  of  pleural  adhesions  to 
operations  on  the  lung;  and  in  1844,  occurred  the  cele- 
brated case  of  Hastings  and  Storks, ^  which  aroused  great 
interest  in  England,  and  a  storm  of  criticism. 

But  in  1850,  Graux,  of  Brussels,  published  thirteen 
cases  of  incision  of  pulmonary  cavities,  without  a  single 
success  ;  and  for  the  next  twenty  years  the  treatment  of 
empyema  was  so  bad  that  there  was  not  likely  to  be  any 
advance  in  the  surgical  treatment  of  the  lung  itself.  A 
further  check  was  given  to  it  by  the  tragic  death  of  a 
surgeon,  who  had  operated  on  both  lungs  of  a  patient 
with  tubercular  phthisis ;  the  patient  died  almost 
immediately,  and  the  surgeon,  being  threatened  with  a 
judicial  enquiry,  put  an  end  to  his  own  life.  About 
1870,  with  Lister,  the  old  order  changed,  giving  place  to 
new;  in  1873,  Mosler,  VV.  Koch,  and  Bull  of  Copen- 
hagen, were  among  those  who  revived  the  surgery  of  the 
lung ;  and  then  come  many  other  names,  both  abroad 
and  in  England,  which,  happily  for  us,  do  not  yet  belong 
to  history.  A  great  quantity  of  experimental  work  was 
now  being  done  on  the  lung  and  its  surgical  treatment; 
perhaps  the  most  important  observations  are  those  of 
Gluck  in  1881,  Block  in  1882,  and  Schmidt  and  Biondi 
in  1884.  A  short  account  of  these  and  other  experiments 
is  given  in  the  chapters  after  this  one. 

For  this  history  of  the  subject,  and  for  a  most  admir- 
able review  of  the  whole  field  of  these  operations,  we 
have   Truc's   important  monograph,2  and  the  excellent 


^"Med.  Times  and  Gaz.,"  Dec.  1844.  See  chapter  on 
"Tubercular  Phthisis." 

^"Essai  sur  la  Chirurgie  du  Poumon,"  Paris,  1885.  See  also 
the  valuable  paper  by  Dr.  Douglas  Powell  and  Mr.  Lyell,  "  Med. 
Chir.  Soc.  Trans.,"  1880,  p.  333. 


288  SURGERY    OF    THE    CHEST. 

address  delivered  last  year  by  Reclus,  before  the  French 
Surgical  Congress.  This  address,  and  the  long  discus- 
sion that  followed  it,  are  of  the  very  highest  value.  I  have, 
therefore,  put  a  full  translation  of  it  as  an  Appendix  to 
this  book :  it  appears  to  me  perfect  alike  in  its  tone  and  in 
its  arrangement  of  the  whole  subject.  Truc's  essay  is,  I 
think,  equally  valuable;  and  if  we  compare  the  two 
writings,  1885  and  1895,  we  may  see  reason  to  believe  that 
the  surgery  of  the  chest  is  now  near  its  greatest  height, 
and  that  its  further  upward  course  is  checked  by  no  fault 
of  its  own,  but  by  restrictions  imposed  on  it  by  the 
natural  limitations  that  are  set  to  all  surgery,  as  things 
are  at  present. 

Diagnosis. 

Probably,  as  with  the  abdomen,  so  with  the  chest, 
surgery  is  just  now  stronger  in  method  than  in  diagnosis^; 
and  there  are  plenty  of  recorded  operations  on  the  lung 
which  were  begun  in  the  belief  that  the  disease  lay 
outside  and  not  inside  it.  Some  examples  of  this  have 
been  already  given ;  and  Frantzel  records  two  cases 
where  he  thought  he  had  to  deal  only  with  an  empyema, 
and  found  instead  a  tubercular  cavity  in  the  lung.  The 
surgeon,  who  has  assured  himself  of  the  presence  of  pus 
within  the  chest,  may  yet  be  wholly  unable  to  make  sure 

' '  The  field  of  lung-surgery  is  still  within  narrow  limits,  if  we 
count  only  those  indications  for  operation  which  seem  to  promise 
complete  success.  It  is  true  that  large  portions  of  the  chest-wall, 
and  of  lung  adherent  to  it,  have  been  removed,  and  that  cases  of 
gangrene,  abscess,  hydatid  disease,  and  bronchiectasis,  have  been 
operated  upon  successfully ;  but  so  many  failures  have  been 
recorded  in  cases  of  this  kind,  that  we  must  learn  to  select  our 
cases  better,  if  we  are  to  improve  our  results  and  our  method  of 
operation.  Most  of  those,  therefore,  who  are  now  working  at 
the  surgery  of  the  lung,  lay  special  emphasis  on  the  necessity  for 
defining  the  exact  indications  for  operation,' — Kochler,  "  Deut. 
Med.  Wchnschr.,"  1895. 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     289 

before  operation  whether  it  is  in  the  pleura  or  in  the 
lung ;  and  the  following  cases,  quoted  by  True,  illustrate 
this  sort  of  unpremeditated  surgery. 

1.  A  man,  aged  44,  was  admitted  to  Hospital  suffering- 
intense  dyspnoea,  with  two  large  abscesses  in  the  neigh- 
bourhood of  the  right  breast,  communicating  with  each 
other.  Pressure  over  them  gave  rise  to  cough  and  abundant 
purulent  expectoration  ;  the  diagnosis  was  therefore  made 
of  empyema,  pointing  under  the  skin,  and  communicating 
with  the  lung.  Incision,  near  the  breast,  let  out  a  large 
quantity  of  pus,  and  gave  him  great  relief ;  but  he  died  a 
day  or  two  later  of  sudden  acute  pleurisy  of  the  opposite 
side.  The  posi  mortem  examination  showed  no  empyema, 
but   a  very  large  abscess  of  the  upper  lobe  of  the  lung. 

2.  A  boy,  aged  6,  was  admitted  to  Hospital  with  cough, 
dyspnoea,  prostration,  and  signs  of  left  pleural  effusion ;  after 
exploratory  puncture,  the  chest  was  incised,  and  twelve 
ounces  of  pus  were  let  out.  The  wound  was  allowed  to  close, 
but  had  to  be  re-opened  and  packed.  Irrigation  caused  cough 
and  pain  in  the  chest,  and,  if  pushed  too  hard,  some  of  the 
lotion  came  through  the  mouth.  Next  day,  the  child  coughed 
up  a  clot  of  blood,  and  similar  clots  were  found  in  the  wound. 
About  a  week  later,  during  irrigation,  the  child  suddenly  felt 
suffocated,  fainted,  and  only  revived  after  artificial  respira- 
tion. A  week  later,  his  general  condition  was  very  bad  ; 
prostration,  delirium,  and  other  signs  of  acute  septicsemia. 
It  was  now  possible  to  make  out  two  communicating  cavities, 
one  in  the  pleura,  containing  clear  fluid,  the  other,  more 
purulent,  in  the  lung.  A  better  method  of  drainage  was  now 
employed,  and  finally  he  made  a  complete  recovery. 

In  some  cases,  it  is  impossible  in  making  the  diagnosis 
of  empyema  to  exclude  the  possibility  of  abscess  of  the 
lung:  in  others,  an  abscess  may  be  present,  but  the 
diagnosis  of  it  may  be  impossible.  It  has  even  been 
proposed  to  divide  these  cases,  from  a  clinical  point  of 
view,  into  latent,  doubtful,  and  certain  ;  the  first  only 
discovered  post  morteju,  the  second  only  suspected,  but 
not  giving  any  clear  sign  of  their  presence,  the  third 
diagnosed  during  life  from  their  symptoms  and  physical 
signs.     Or  the  surgeon   may  be  able   to  diagnose   and 

19 


290  SURGERY    OF    THE    CHEST. 

localize  suppuration  in  the  lung,  and  yet  may  not  know 
whether  he  has  to  deal  with  a  simple  abscess,  gangrene, 
bronchiectasis,  or  a  tubercular  cavity.  Or  he  may  exactly 
diagnose  and  treat  an  abscess,  and  yet  fail  to  cure  his 
patient  because  there  are  other  cavities,  elsewhere  in  the 
lung,  that  he  has  left  unopened  or  undrained. 

Again,  to  increase  the  difficulty  of  diagnosis,  there  may 
be  no  profuse  purulent  expectoration,  no  loss  of  vocal 
vibration  over  the  cavity. ^  But  in  most  cases,  the 
history  of  a  previous  acute  inflammation,  or  of  some 
condition  likely  to  cause  septic  embolism,  and  the  physi- 
cal signs  of  localized  dulness  and  loss  of  breath  sounds, 
pain,  fever,  and  embarrassed  breathing,  a  localized  tender- 
ness on  pressure,  the  appearance  of  pus  in  the  sputa,  and 
perhaps,  under  the  microscope,  the  admixture  of  elastic 
fibres  or  of  blood  pigment— this  state  of  things,  together 
with  the  absence  of  any  clear  evidence  of  tubercular 
phthisis  or  of  pulmonary  gangrene,  may  lead  the  surgeon 
at  least  to  suspect  an  abscess  of  the  lung,  and  to  act 
on  his  suspicions. 

Cases  illustrating  Abscess  of  Lung. 

The  following  cases-  will  illustrate  some  of  these  many 
difficulties  of  diagnosis,  and  raise  questions  of  treatment 
which  we  must  carefully  attempt  to  estimate.  The  first 
is  of  interest  for  its  age,  as  well  as  for  its  own  sake. 

I.  In  1753,  a  man,  aged  30,  was  admitted  to  Hospital  nine 
days  after  the  onset  of  acute  inflammation,  with  severe  pain 
in  the  right  side  of  the  chest,  worse  on  pressure  over  the  seat 

'See  Dr.  Porter's  essay  on  Abscess  of  the  Lung,  "Journ.  Amer. 
Med.  Ass.,"  March  7,  1891. 

=  For  references,  in  addition  to  those  already  given,  see 
Hofmokl,  'BeitriigezurLungen-Chirurgie,'  "  Wien.Med.  Presse," 
1892  ;  Fairchild,  "  Wien.  Med.  Wchnschr.,"  1893,  p.  833 ;  Teale, 
"  Lancet,"  June  5th,  1884. 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     291 

of  pain.  The  day  after  admission,  there  was  profuse  purulent 
expectoration,  which  became  persistent  ;  the  pain  remained 
unmoved  without  the  least  variation,  always  at  the  same 
place,  and  it  was  noted  that  the  soft  parts  here  were  swollen. 
The  patient  refused  operation  for  no  less  than  three  months, 
and  steadily  lost  ground  ;  at  the  end  of  this  period,  an 
incision  was  made  through  the  swelling,  and  air  escaped 
with  such  force  as  to  blow  out  a  candle  ;  no  pus  came  with 
it,  but  an  hour  later  there  was  a  profuse  discharge.  For 
some  days  the  patient  continued  to  become  more  and 
more  enfeebled  by  the  profuse  suppuration,  but  he  finally 
made  a  complete  recovery. 

2.  A  man,  aged  44,  was  taken  ill  in  December,  1880, 
with  shiverings,  vomiting,  pain  about  the  region  of  the  liver, 
and  loss  of  flesh  ;  no  cough,  no  signs  of  disease  of  the  lung. 
On  March  ist,  1881,  he  had  signs  of  right  pleural  efl'usion  ; 
aspiration  over  the  base  of  the  lung  gave  only  a  few  drops  of 
yellowish  purulent  fluid,  but  somewhat  higher  up  it  drew  off 
a  whole  pint  of  greyish  pus  ;  there  was,  therefore,  a  double 
cavity,  or  two  cavities.  On  March  i6th,  his  general  condition 
was  worse,  and  he  had  foetid  expectoration  ;  there  were  signs 
that  the  cavity  contained  air  as  well  as  fluid  ;  puncture  above 
and  a  little  in  front  of  the  angle  of  the  scapula  showed  the 
pus  was  foetid,  and  an  incision  (without  anaesthetic)  was 
made  into  the  pleura.  Only  a  small  quantity  of  serum 
flowed  out ;  the  surface  of  the  lung  was  uneven,  and  slightly 
adherent  here  and  there;  the  lung  itself  felt  hard,  doughy, 
inelastic,  and  non-crepitant.  An  opening  was  made  into  it 
with  the  trochar  and  the  finger,  and  two  pints  of  extremely 
foetid  fluid  were  let  out.  For  a  very  long  time — several 
months — he  was  dangerously  ill  with  all  the  signs  of  chronic 
septicaemia  ;  finally,  after  a  profuse  diarrhoea,  he  began  to  im- 
prove, and  made  a  complete  recovery.  The  drain  was  not 
left  out  till  nearly  the  end  of  August. 

3.  A  woman,  aged  24,  was  admitted  to  Hospital  on  July 
13th,  1882,  desperately  ill,  with  the  signs  of  a  large  collection 
ot  air  and  fluid  in  the  right  side  of  the  chest.  In  childhood, 
she  had  frequently  had  pneumonia,  and  at  15,  'typhus'  ; 
four  years  ago,  she  had  suffered  an  attack  of  nephritis,  with 
jaundice,  and  profuse  foetid  expectoration.  On  admission, 
she  was  emaciated,  exhausted  ;  feeble  pulse,  dyspnoea,  in- 
tense jaundice,  profuse  foetid  expectoration,  about  a  pint  and 
a  half  daily.  A  piece  of  rib  was  resected,  Paquelin's  cautery 
was  passed  into  the  lung  in  the  axillary  line,  and  a  cavity 
was  found  in  it  the  size  of  the  fist,  e.xtending  downward  to 


292  SURGERY    OF    THE    CHEST. 

the  diaphragm,  traversed  by  bridles  of  fibrous  tissue.  These 
having  been  destroyed  with  the  cautery,  aspirating  needles 
were  pushed  through  the  wall  of  the  cavity,  and  found  foetid 
pus  ;  and  the  cautery,  passed  along  the  track  of  the  needles, 
opened  a  huge  cavity  the  size  of  a  child's  head,  full  of  foetid 
pus  and  debris  of  lung  tissue.  It  was  drained  and  irrigated  ; 
the  dyspnoea  ceased,  but  the  patient  was  too  far  gone  to 
recover,  and  died  a  week  after  the  operation. 

4.  A  man,  aged  37,  was  admitted  to  Hospital  on  March 
6th,  1883  ;  he  had  been  subject  to  cough  lor  a  year  and  a 
half,  but  never  laid  up  with  it  ;  on  admission,  he  had  shiver- 
ings,  pain  in  the  side,  loss  of  appetite,  slight  fever  ;  there 
were  physical  signs  of  one  or  more  cavities  at  the  apex  of  the 
right  lung  ;  he  was  somewhat  cyanosed,  his  breath  was  foetid, 
and  his  daily  expectoration  amounted  to  half  a  pint,  and  con- 
tained pus,  epithelial  cells,  and  elastic  fibres,  but  no  tubercle 
bacilli.  The  first  exploratory  puncture,  in  the  second  space, 
failed  ;  the  next,  in  the  same  space,  let  out  a  little  fluid  con- 
taining pus  cells  and  altered  pulmonary  epithelial  cells.  A 
piece  of  the  second  rib  was  resected,  and  a  trochar  and 
cannula  were  pushed  into  the  lung  ;  the  track  was  dilated, 
and  a  thick-walled  cavity,  ti^aversed  by  a  tough  bridle  of 
fibrous  tissue,  was  found.  There  had  been  no  oscillation  of 
the  exploring  needle,  and  the  operation  was  not  followed  by 
pneumothorax.  The  cavity  was  drained  and  irrigated, 
and  he  healed  well,  though  he  was  feverish  for  a  fortnight 
after  the  operation,  and  also  had  slight  poisoning  from  car- 
bolic acid.  In  October  the  scar  gave  way,  and  a  large 
quantity  of  pus  escaped  ;  then  all  healed,  and  he  remained 
well. 

5.  A  man,  aged  55,  convalescent  after  pneumonia,  was 
again  taken  ill,  with  a  rigor,  cough,  and  purulent  expectora- 
tion, and  in  spite  of  careful  nursing  got  steadily  worse.  The 
breath-sounds  were  weak  in  front,  and  wholly  lost  over  part 
of  the  lung  behind,  where  there  was  also  dulness  on  percussion. 
Several  attempts  to  find  pus  with  the  aspirating  needle  were 
unsuccessful  ;  at  last  it  was  found  on  puncturing  the  fifth 
space  just  in  front  of  the  angles  of  the  ribs.  The  needle  was 
left  in  as  a  guide,  and  a  piece  of  the  fifth  rib  was  resected  ; 
a  large  cavity  in  the  lung  was  found  shut  off  from  the  pleura 
by  adhesions,  and  eleven  ounces  of  pus  let  out  ;  free  drainage 
and  irrigation  were  used,  and  he  slowly  made  a  good 
recovery. 

6.  A  man,  aged  32,  suffered  pneumonia  of  the  right  side 
at  the  age  of  25,  and  had  been  subject  to  cough  from  that 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     293 

time  onward.  A  fortnight  before  admission  to  Hospital, 
after  exposure  to  cold,  he  had  rigors,  fever,  and  severe  fits 
of  coughing,  with  profuse  foetid  expectoration  ;  and  he  now 
presented  physical  signs  of  a  cavity  in  the  lower  part  of  the 
right  lung,  and  of  recent  pleurisy  on  the  left  side.  A  piece 
of  the  seventh  right  rib  was  resected,  below  the  angle  of  the 
scapula.  There  were  pleural  adhesions,  the  pleura  itself  had 
a  greyish  tint,  and  the  lung  beneath  it  felt  unduly  hard.  The 
point  of  a  Paquelin  cautery  was  sunk  into  the  lung  in  differ- 
ent directions  to  a  depth  of  i  to  2  inches  ;  and  at  the  fourth 
puncture  (2 J  inches  deep,  passing  backward  and  inward) 
some  air  and  a  httle  purulent  mucus  escaped.  The  wound 
was  left  open,  and  packed  with  gauze.  He  immediately 
began  to  improve,  and  rapidly  recovered. 

7.  A  woman,  aged  25,  having  signs  of  an  abscess  within 
the  chest,  communicating  with  the  air-passages,  gave  the 
following  history.  When  she  was  only  12  years  old,  she  had 
suddenly,  after  a  cold,  showed  signs  of  a  cavity  in  or  opening 
into  the  lung,  and  for  fourteen  years  had  never  for  a  day 
been  free  from  more  or  less  profuse  purulent  expectoration  ; 
but  her  general  health  had  been  fairly  good,  except  that  at 
times  she  was  thin  and  weak,  and  the  sputa  were  then 
especially  offensive.  In  1892,  after  an  attack  of  influenza, 
she  had  purulent  pleurisy  of  the  left  side,  which  was  treated 
with  incision  of  the  fifth  space  in  the  anterior  axillary  line, 
and  drainage  for  a  iortnight.  Her  general  condition  was 
now  very  grave  ;  she  was  weak,  pale,  emaciated,  and  unable, 
for  shortness  of  breath,  to  walk  or  make  the  least  effort. 
The  physical  signs  (amphoric  breathing,  occasional  gurgling 
sounds,  and,  at  a  point  between  the  angle  of  the  scapula  and 
the  spine,  well-marked  sounds  of  air  bubbling  through  fluid) 
led,  after  repeated  examinations  by  many  physicians,  to  the 
following  diagnosis  :  Chronic  bronchitis,  with  general  dilata- 
tion of  bronchi  over  the  whole  of  the  left  lung;  circumscribed 
empyema  of  the  lower  part  of  the  left  pleura,  probably 
secondary  to  gangrene  of  the  lung  ;  and  a  fistulous  opening 
between  the  pleura  and  the  lung.  The  expectoration  was 
profuse,  purulent,  and  horribly  foetid  ;  it  came  in  a  rush  two 
or  three  times  a  day,  after  a  paroxysm  of  coughing  and 
choking,  and  not  continuously  ;  repeated  examinations  of  it 
failed  to  find  the  tubercle  bacillus. 

Operation,  May  9th,  1894.  Resection  of  seventh  and 
eighth  ribs  near  the  spine  ;  the  pleura  was  thick,  tough,  and 
firmly  adherent  ;  the  lung  was  alasolutely  hard,  and  scarcely 
bled  on  incision  ;  a  huge  cavity  of  the  whole  of  the  lower 


294  SURGERY    OF    THE    CHEST. 

lobe  was  laid  open.  Its  Iront  wall,  of  a  very  thin  layer  o! 
condensed  lung-tissue,  covered  the  pericardium,  and  the 
movements  of  the  heart  were  plainly  visible  ;  its  walls  were 
smooth,  even,  of  a  greyish  tint,  covered  here  and  there  with 
bronchial  mucus  ;  it  was  ten  inches  in  vertical  measurement, 
running  upward  as  high  as  the  fifth  space,  in  the  shape  of  a 
narrow  sac  constricted  here  and  there.  The  eighth  and  ninth 
ribs  were  now  very  freely  resected,  and  a  large  opening  was 
made  into  the  huge  cavity,  and  it  was  packed  with  sponges  and 
sterilized  gauze.  The  patient  at  once  began  to  amend  ;  and 
after  some  subsequent  operation  in  July  for  the  cure  of  a 
fistulous  track  that  remained  after  the  operation,  she  made  a 
complete  recovery. 

Careful  study  of  these  cases  will  put  us  in  possession 
of  the  chief  facts  of  the  nature,  course,  and  treatment  of 
abscess  of  the  lung.  It  is  evident  that  a  right  diagnosis 
may  be  hindered  by  difficulties  that  are  almost  insuper- 
able, and  that  the  disease  ranges  from  a  single  huge 
excavation  of  the  lung  to  a  condition  practically  the  same 
as  bronchiectasis.  Again,  it  may  closely  imitate  tuber- 
cular phthisis,  acute  gangrene  of  the  lung,  or  empyema 
communicating  with  the  air  passages  ;  and  from  the  wide 
range  of  the  disease,  and  its  resemblance  to  other  morbid 
conditions,  it  must  often  be  doubtful  whether  an  opera- 
tion is  likely  to  be  successful,  or  is  even  advisable. 

Cases  illustrating   Bronchiectasis. 

I  give  next  some  cases^  of  operation  for  bronchiectasis: 
it  will  be  noted  that  this  condition  is,  on  the  whole,  un- 
hopeful. The  surgeon  may  give  relief,  but  can  hardly 
hope  to  effect  the  permanent  cure  of  his  patient ;  his 
chance  of  success  is  in  inverse  proportion  to  the  number 
of  small  separate  cavities  in  the  lung  ;  and  the  specimen 
{Fiate  VIII)  shows  clearly  how  this  disease  tends  to  pass 

'  See  True,  p.  59 ;  Biss,  "Med.  Chir.  See.  Trans.,"  1SS4,  p.  217; 
Hofmokl,  "  Wien.  Med.  Presse,"  1892,  p.  1904. 


Plate  viii. 


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Advanced  Bronchiectasis  of  the  Lower  Part  of  one  Lung :  showing  multiple 
small  cavities,  illustrating  cause  of  failure  in  operation  for  this  disease.  (From 
a  specimen  in  the  Royal  College  of  Surgeons'  Museum.) 


\Face  /.  2()4. 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     293 

beyond  the  help  of  surgery.  I  believe  that  the  opinion 
of  M.  Reclus  (see  Appendix)  represents  fairly  the  general 
estimate  that  surgeons  have  formed  of  operation  for  this 
condition. 

1.  A  man,  aged  25,  who  had  for  seven  years  suffered  from 
cough  and  weak  chest,  was  admitted  to  Hospital  on  Nov. 
22nd,  1882.  Nearly  two  years  ago,  he  had  been  attacked  by 
pleurisy  of  the  right  side — no  effusion.  For  the  last  nine 
months  his  cough  had  been  severe,  widi  profuse  expectoration. 
The  right  side  of  the  chest  was  sunken,  and  the  lower  pkrt  of 
it  did  not  move  in  respiration  ;  general  bronchitis,  friction- 
sounds  over  the  base  of  the  left  lung  ;  over  the  right  lung" 
behind,  below  the  angle  of  the  scapula,  dulness,  loss  of 
breath-sounds  and  of  vocal  vibration  ;  slight  fever,  allDumin- 
uria  ;  profuse  foetid  expectoration.  Aspiration  of  the  dull 
area  drew  off  some  sero-purulent  fluid  ;  and,  two  days  later, 
percussion  here  gave  a  tympanitic  note,^  and  there  was 
cavernous  breathing,  with  coarse  rales.  Diagnosis.,  general 
bronchiectasis,  with  a  large  cavity,  thickened  lung,  adhesions 
at  the  right  base.  Ope7-atio?i.,  Nov.  25th  :  incision  of  ninth 
space,  outside  the  scapular  line  ;  a  deep  track  was  made 
into  the  lung,  with  the  Paquelin's  cautery  and  the  finger,  but 
no  cavity  of  any  considerable  size  was  found.  Fcetid  gas 
came  from  the  wound  in  the  limg"  ;  it  was  plugged  for  a 
few  hours,  and  then  drained.  No  improvement  followed  the 
operation  ;  subsequent  exploratory  punctures  gave  no  result  : 
the  patient  died  a  month  after  the  operation.  Post  morteiu., 
the  opening  in  the  lung  led  through  a  narrow  sinus  into  a 
dilated  bronchus  ;  in  the  base  of  the  lung  were  a  number  of 
reticulate  dilatations,  but  no  large  cavity. 

2.  A  man,  aged  32,  who  gave  a  history  of  only  six 
months'  illness,  was  admitted  to  Hospital  on  Oct.  3rd,  1883, 
with  cough,  profuse  expectoration,  which  had  lately  become 
offensive,  night-sweats,  shortness  of  breath,  loss  of  flesh,  and 
occasional  htemoptysis.  There  was  bulging  in  the  right 
scapular  region,  and  below  it  ;  dulness,  loss  of  breath-sounds 
and  of  vocal  vibration,  and,  on  Oct.  loth,  a  diffused  friction 


'Dr.  Porter  {J,oc.  cit.)  gives  a  case  of  gangrenous  abscess  of  the 
lung,  where,  in  addition  to  the  usual  signs  of  abscess,  there  was 
marked  tympanites  at  the  seat  of  the  lesion,  which  would  be 
removed  by  severe  coughing,  leaving  an  area  of  dulness  well 
marked. 


296  SURGERY    OF    THE    CHEST. 

sound.  A  week  later,  as  in  case  i,  the  signs  were  changed,^ 
and  there  was  marked  cavernous  breathing,  with  broncho- 
phony, and  fine  crepitations.  Puncture,  on  four  occasions, 
failed  to  find  pus  ;  and  in  December  there  was  no  improve- 
ment, and  he  was  coughing  daily  a  pint  of  watery,  purulent, 
and  somewhat  offensive  sputa.  Operation,  Dec.  23rd,  the 
area  of  cavernous  breathing  and  pectoriloquy  was  carefully 
marked  out,  and  an  incision  was  made  over  the  centre  of  it, 
in  the  tenth  space,  in  the  scapular  line.  There  were  dense 
pleural  adhesions.  A  trochar  and  cannula  were  pushed 
forward  into  the  lung  for  about  four  inches,  and  then  seemed 
to  enter  a  small  cavity,  for  air  came  out  in  puffs,  and  was 
distinctly  foetid  ;  a  probe  could  be  passed  from  the  cavity 
along  a  bronchus.  The  lung  was  kept  drained,  and  the 
patient  was  much  improved  ;  the  temperature  fell  almost  to 
normal,  good  appetite,  less  cough,  much  less  expectoration. 
He  died  in  February,  1884,  of  cerebral  abscess.  Post 
/no?-fe!?i,  the  pleura  was  enormously  thickened,  and  every- 
where adherent  ;  the  lung  was  much  contracted,  and  con- 
tained a  number  of  multilocular  thin-walled  cavities  of 
different  sizes,  continuous  with  dilated  bronchial  tubes,  and 
containing  whitish,  mortary,  exceedingly  foetid  matter.  The 
operation -wound  led  into  one  of  the  largest  of  them. 

3.  A  man,  aged  25,  worker  in  a  felt  factory,  had  for  four 
years  been  subject  to  cough,  but  without  expectoration,  till  a 
fortnight  before  admission  to  Hospital,  when  he  suddenly 
began  to  have  profuse  and  foetid  sputa.  There  was  oedema 
of  the  lower  limbs,  bedsore  over  the  sacrum,  night  sweats, 
loss  of  flesh  ;  signs  of  a  cavity  in  the  upper  part  of  the  left 
lung  ;  he  was  going  from  bad  to  worse,  in  spite  of  treat- 
ment. Operation,  Sept.  29th,  1892  :  incision  four  inches 
long,  through  second  left  space  in  front  ;  pleura  adherent, 
and  of  greyish  tint,  lung  harder  than  natural.  Attempts 
made  with  a  director  failed  to  find  a  cavity  ;  the  wound  was 
therefore  packed  with  gauze.  Second  operatip7t,  Nov.  4th, 
sub-periosteal  resection  of  three  to  four  inches  of  third  rib, 
beginning  about  an  inch  from  edge  of  sternum  ;  a  Paquelin's 
cautery  was  passed  in  different  directions  into  the  chest,  and 
at  the  fourth  attempt  there  came  air  and  a  quantity  of  fcetid 
fluid.  Unhappily,  it  was  thought  necessary  to  dilate  the 
track  into  the  lung  ;  and  this  caused  profuse  haemorrhage, 

'  A  similar  change  of  the  breath-sounds  was  noted  in  cases 
published  by  Dr.  H.  Hawkins  and  Dr.  Alexander  Morison, 
"  Clin.  See.  Trans.,"  1891  and  1893. 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     297 

so  that  the  patient  was  almost  suffocated.  The  lung-  was 
immediately  plugged,  and  ergotin  was  injected  under  the  skin. 
He  made  a  rapid  recovery,  regained  his  full  health  and 
strength,  and  was  discharged  from  Hospital  on  14th  of 
November. 

Chances  of  Success  of  Operation. 

From  these  cases  of  abscess  and  bronchiectasis  that  I 
have  quoted,  we  may  get  a  fair  idea  of  the  surgical  treat- 
ment of  cavities  of  the  lung  not  due  to  tubercular  disease 
or  to  acute  gangrene.  We  see  that  simple  abscess  and 
bronchiectasis,  though  they  are  of  different  origins  and  run 
different  courses,  are  not  sharply  defined  from  each 
other  surgically.  But  if  we  take,  on  the  one  hand,  cases 
of  large  single  simple  abscess  of  the  lung,  and,  on  the 
other,  cases  of  advanced  bronchiectasis,  where  a  great 
part  of  the  lung  is  riddled  with  small  irregular  tortuous 
cavities,  we  see  how  different  the  chances  of  successful 
operation  must  be  in  these  two  diseases.  And  this 
difference  is  well  shown  in  the  following  statistics 
published  by  Trzebicki  in  Sept.  1892,  of  all  the  cases  of 
operations  on  the  lung  recorded  up  to  that  date  : — ■ 

I. — Simple  abscess  of  the  lung  :  42  operations.  14 
complete  recoveries,  3  recoveries  with  fistulce,  24  deaths, 
I  result  unknown. 

2. — Bronchiectasis  :  12  operations.  No  complete  re- 
coveries, I  not  yet  healed,  8  deaths,  3  result  unknown. 

3- — Gangrene  of  the  lung :  24  operations.  7  com- 
plete recoveries,  i  recovery  with  fistula,  i  not  yet  healed, 
13  deaths,  2  result  unknown. 

4- — Tubercular  cavity  :  24  operations.  5  complete 
recoveries,  5  not  yet  healed,  9  deaths, ^  5  result  unknown. 

5. — Hydatid   cyst :    45   operations.     37    complete  re- 

'  One  of  these  deaths  did  not  occur  till  three  years  after  the 
operation. 


29S  SURGERY    OF    THE    CHEST. 

coveries,  i  recovery  with  fistula,  6  deaths,  i  result  un- 
known, 

6. — Resection  of  lung  tissue  :  5  operations,  i  com- 
plete recovery,  4  deaths. 

Hofmokl's  statistics  (1892)  tell  the  same  story.  'As 
regards  my  own  work,'  he  says,  '  putting  aside  the  cases 
of  tubercular  cavities,  hydatid  cysts,  and  new  growths, 
and  taking  only  abscess,  bronchiectasis,  and  gangrene,  I 
have  had  80  cases.  The  best  results,  out  of  these  three, 
were  those  of  simple  abscess  :  the  worst  were  those  of 
bronchiectasis,  where  out  of  14  cases  only  2  made  a 
complete  recovery  after  operation.' 

Operation. 

We  need  not  here  endeavour  to  estimate  those  signs 
and  symptoms  which  guide  the  physician  to  diagnose  a 
suppurating  non-tubercular  cavity  in  the  lung,  and  to 
advise  that  an  operation  should  be  performed.  From  a 
purely  surgical  point  of  view,  the  interest  of  the  case 
begins  with  the  exploratory  puncture  with  a  suitable 
needle  and  syringe.  The  surgeon  is  very  likely  to  fail  to 
find  anything  :  even  if  his  needle  does  enter  the  cavity, 
the  pus  may  be  too  thick  to  flow  through  it,  or  the 
cavity  may  be  almost  empty,  the  pus  having  been  dis- 
charged through  the  mouth  by  a  recent  fit  of  coughing.  1 
But  if  he  does  find  pus,  then  his  needle  may  serve  two 
further  uses  :  it  guides  him  to  the  cavity,  and,  if  it  does 


^  In  one  case,  of  bronchiectasis  plus  localized  empyema,  the 
needle  entered  the  cavity,  but  the  contents  of  it  were  too  thick  to 
flow  through  it ;  and  it  is  possible  that  the  needle,  as  it  was 
withdrawn,  infected  the  empyema,  for  at  the  time  of  opera- 
tion it  was  foetid.  In  another  case,  the  physician  took  care  to 
give  the  cavity  time  to  refill  after  a  fit  of  coughing,  before  he 
punctured  it,  and  was  successful  in  finding  pus.  (Dr.  H. 
Hawkins,   '  Abscess  of  Lung,'  "Clin.  Soc.  Trans,,"  1891,  p.  91.) 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     299 

not  oscillate  with  the  movements  of  respiration,  but  is 
simply  lifted  up  and  down  with  the  whole  wall  of  the 
chest,  it  goes  to  prove  that  there  are  adhesions  between 
the  lung  and  the  pleura.  Other  things  may  help  him  to 
feel  sure  of  their  presence  ;  the  sensation  of  the  needle 
passing  through  thick  tough  tissue,  the  history  of  pre- 
vious pain,  or  of  a  friction-sound,  the  long  duration  of 
the  disease,^  the  physical  signs,  the  contraction  or 
limited  movement  of  that  side  of  the  chest. 

It  is,  of  course,  essential  that  the  cavity  in  the  lung 
should  before  incision  be  shut  off  from  the  pleura.  In 
these  less  acute  conditions,  adhesions  are  seldom  absent, 
unless  the  cavity  be  of  recent  origin,  or  far  from  the 
surface  of  the  lung.  But  if  the  surgeon,  having  divided 
the  soft  tissues,  should  find  the  pleura  not  thickened,  and 
should  see  the  lung  moving  freely  beneath  it,  he  must  be 
prepared  to  do  something  to  shut  off  the  pleura.  Krimer, 
about  1830,  operating  for  a  cavity  in  the  lung,  found  no 
adhesions  •  as  soon  as  he  opened  the  pleura,  the  lung  at 
once  collapsed,  and  could  not  be  drawn  forward,  and  the 
operation  had  to  be  abandoned.-  The  older  surgeons 
advised  that,  if  there  were  no  adhesions,  caustic  should 
be  laid  to  the  pleura  for  some  days  before  it  was  incised  ; 
but  it  is  better,  in  accordance  with  more  recent  teaching, 
to  suture  the  lung  to  the  pleura."'  Should  there  be 
reason   to   fear   that   any  of  the   pus   in   the   cavity  has 


' '  At  any  time  after  three  or  four  weeks  (judging  from  other 
cases  of  pleurisy)  adhesions  would  be  sufficiently  firm.'  Douglas 
Powell  and  Lyell,  on  'A  Case  of  Basic  Cavity  of  the  Lung 
treated  by  Paracentesis.'  "  Med.  Chir.  Soc.  Trans.,"  1880,  p. 
333- 

-  It  is  to  be  noted  that  the  collapse  of  the  lung  emptied  the 
cavity,  the  pus  flowed  freely  through  the  patient's  mouth,  and  he 
was  for  a  time  relieved. 

3  For  references  to  this,  see  Chapters  XX.  and  XXI. 


300  SURGERY    OF    THE    CHEST. 

found  its  way  into  the  pleura,'  an  incision  ought  at  once 
to  be  made  low  down  into  the  pleura,  and  free  drainage 
provided. 

There  is  no  one  method  of  reaching  the  cavity  in  the 
lung.  Some  surgeons  prefer  the  Paquelin's  cautery ; 
others  a  director,  or  the  knife,  or  a  trochar  and  cannula  ; 
the  right  method  must  depend  on  the  depth  and  vascu- 
larity of  the  lung-tissue  over  the  cavity.  Many  instruments 
have  been  invented  for  opening  a  track  through  the  lung 
with  a  maximum  of  accuracy  and  a  minimum  of  danger  ; 
one  of  the  best  of  them  is  a  fine  director  fitting  close 
round  the  needle  of  an  exploring  syringe,  as  a  cannula 
fits  a  trochar,  so  that  needle  and  director  enter  the  lung 
together,  and  when  the  needle  is  withdrawn,  the  director 
is  left  behind  as  a  guide.  This  instrument  seems  to  me 
better  than  one  which  I  had  made  for  me  some  years 
ago — a  long,  sharp-pointed,  deep-grooved  handleless 
director,  the  same  size  all  along,  graduated  in  half-inches, 
with  a  set  of  tubes  of  different  lengths  to  slide  over  it. 
Whatever  instrument  is  used,  the  surgeon  must  go 
slowly ;  he  must  be  very  careful  how  he  dilates  the 
track  ;  he  must  be  content,  if  there  be  much  bleeding,  to 
plug  the  wound  in  the  lung  rather  than  risk  the  life  of 
his  patient  by  letting  blood  pour  into  the  air-passages. 

There  is  no  need  of  a  long  list  of  cases,  to  illustrate  all 
the  doubts  and  difficulties  that  attend  the  surgical  treat- 
ment of  a  suppurating  non-tubercular  cavity  of  the  lung. 
The  surgeon  must,  in  the  common  phrase,  look  at  the 

'  This  accident  has  in  several  cases  proved  fatal.  It  may  occur 
even  though  there  are  adhesions.  Thus,  in  one  case  where  a 
small  cavity  was  opened  and  drained,  the  patient  was  found, 
three  days  after  the  operation,  to  have  a  general  empyema, 
'  doubtless  owing  to  disturbance  of  the  pleural  adhesions  during 
the  necessary  manipulations.'  It  was  at  once  opened  and 
drained.     The  patient  made  a  complete  recovery. 


ABSCESS  OF  THE  LUNG.     BRONCHIECTASIS.     301 

case  all  round  ;  remembering  that  a  cavity  near  the  apex  ^ 
maydrain  into  the  bronchi,  and  maythus  be  healed  without 
operation,  but  one  in  or  near  the  base  cannot ;  and  that 
his  chance  of  permanent  success  is  small  indeed  if  the 
cavity  be  only  part  of  a  widespread  bronchiectasis.  But, 
even  in  these  cases,  he  must  interfere,  if  the  patient 
be  steadily  losing  ground,  and  in  danger  of  death  from 
septic  absorption,  or  infection  of  the  opposite  lung,  or 
breaking  of  the  cavity  into  the  pleura.  He  must  remem- 
ber that  the  disease  of  the  lung  may  be  combined  with  a 
purulent  pleural  effusion.  He  must  find  adhesions, 
or  must  shut  off  the  pleura.  If  there  be  a  large  cavity, 
traversed  by  bridles  of  fibrous  tissue,  he  must  leave  these, 
and  not  break  them  down,  lest  he  should  provoke 
haemorrhage.  Finally,  he  has  the  encouragement  of  a 
long  record  of  successful  cases:  and  yet  it  is  less  than 
twenty  years  since  Trousseau^  laid  down  the  rule  that  an 
abscess  of  the  lung  was  altogether  beyond  the  reach  of 
surgery. 


lA  very  valuable  case  of  abscess  near  the  apex  of  the  lung, 
appearing  to  open  into  the  posterior  mediastinum,  has  been 
recorded  by  Dr.  Alexander  Morison,  "  Clin.  Soc.  Trans.,"  1893; 
Mr.  Bryant  reached  it  through  the  third  intercostal  space,  be- 
tween the  spine  and  the  scapula. 

^ '  Une  fois  I'abces  forme,  notre  intervention  ne  saurait  avoir 
prise  sur  une  affection  de  cette  nature,  placee  tout  a  fait  en 
dehors  de  nos  moyens  d'action.'— "  Clinique  Medicale,"  1877. 


302 


CHAPTER   XX. 

GANGRENE    OF    THE    LUNG. 

It  is  not  possible,  for  the  purposes  of  this  book,  to  keep 
gangrene  wholly  separate  from  other  diseased  states  of 
the  lung.  Bronchiectasis,  foetid  empyema,  sloughing  of 
the  bronchial  glands,  foreign  bodies  in  the  bronchi,  are 
all  so  closely  related  to  gangrene  of  the  lung  that  it  can 
hardly  be  considered  apart  from  them.  It  arises  under 
many  different  conditions,  and  runs  a  very  uncertain 
course.  It  often  presents  great  difficulties  of  diagnosis, 
and  even  those  cases  that  require  operation  may  pass 
beyond  the  reach  of  help  without  ever  having  given  clear 
indications  for  surgical  interference. 

Many,  again,  never  come  within  the  range  of  surgery. 
Gangrene  of  the  lung,  from  severe  crushing  of  the  chest, 
or  from  a  mass  of  malignant  disease  compressing  the 
pulmonary  vessels  at  their  origins,  is  more  likely  to  be 
diffused  than  to  be  circumscribed  ;  and  that  form  of  it 
also  which  occurs  in  diabetic,  insane,  or  alcoholic  patients, 
usually  ends  in  death  without  becoming  circumscribed. 
Obstruction  of  the  main  bronchus  near  its  origin,  and 
infection  of  the  whole  lung  by  the  entry  of  septic 
matter  into  the  air-passages,  tend  in  the  same  way 
either  to  diffuse  gangrene,  or  to  the  formation  of  a 
gangrenous  cavity  so  deep  in  the  lung  as  to  be  almost 
inaccessible. 

Simple  acute  pneumonia,  in  a  patient  otherwise  healthy, 
very  rarely  leads  to  gangrene ;  but  septic  pneumonia,  or 
inflammation  of  the  lung  in    those  who  are  in   feeble 


GANGRENE    OF    THE    LUNG.  303 

health,  or  reduced  by  some  chronic  disease  or  by  drink, 
sometimes  ends  in  gangrene  involving  perhaps  a  whole 
lobe  of  the  lung.  Andral,  in  583  post  mortem  examina- 
tions, in  cases  of  pneumonia,  found  gangrene  in  52,  or 
y2)  pel'  cent.  Huss,  in  2,166  cases  of  pneumonia,  met 
with  only  twelve  instances,  in  men  from  35  to  55  years 
old,  every  one  exhausted  in  health.  Dr.  Charles  West 
says  that  the  lung  in  childhood  shows  a  much  greater 
tendency  to  pass  into  a  state  of  gangrene  than  in  adult 
age ;  but  this  is  not  seen  in  the  acute  pneumonia  of 
children,  and  instances  only  occur  singly  in  the  works  of 
different  authors.  Ziemssen  met  with  it  only  once  in  201 
cases  of  primary  pneumonia  in  children. 1  Htemorrhage 
into  the  lung-tissue,  pulmonary  apoplexy,  may  be  followed 
by  gangrene,  and  this  is  more  likely  to  be  circumscribed 
than  diffused.  But  the  cases  where  we  have  most  reason 
to  hope  that  the  disease  is  both  circumscribed  and  super- 
ficial, are  those  where  it  is  due  to  a  minute  embolus 
blocking  one  of  the  terminal  branches  of  the  pulmonary 
artery,  as  in  those  published  by  Trousseau,  and  by  Dr. 


■'  These  figures  are  given  in  Dr.  Wilson  Fox's  article  on  Pneu- 
monia, in  Russell  Reynold's  "  System  of  Medicine,"  1871,  vol. 
iii.,  p.  672.  He  says,  'Gangrene  after  pneumonia  is  very  rare ; 
still,  some  well-authenticated  instances  are  recorded,  and  it 
appears  that  an  epidemic  influence  may  at  times  predispose  to 
its  occurrence.  Hughes  ("  Guy's  Hospital  Reports,  1848")  found 
28  cases  of  gangrene  in  200  post  mortem  examinations  of  pneu- 
monia. At  one  time,  it  was  noted  that  several  cases  of  gangrene 
appeared  during  the  prevalence  of  an  epidemic  of  influenza,  and 
that  as  many  as  six  cases  occurred  in  one  week.  It  commonly 
appears  late  in  the  disease,  but  it  has  been  seen  as  early  as  the 
fifth  day.  In  fifty-three  cases  of  which  I  possess  observations, 
I  have  found  two  instances  of  gangrene,  and  in  both  these  it  was 
irregularly  diffused  through  scattered  spots  of  pneumonic  infil- 
tration. Its  site,  according  to  Huss's  observations,  is  most 
commonly  in  the  lower  lobe,  and  it  has  almost  invariably 
occurred  in  exhausted  constitutions.  In  tubercular  pneumonia, 
it  is  much  more  common.' 


304  SURGERY    OF    THE    CHEST. 

Cayley  with  Mr.  Pearce  Gould. ^  In  one,  embolism  was 
due  to  phlegmasia  dolens  of  the  leg  ;  in  the  other,  to 
caries  of  the  mastoid. 

Unhappily,  where  there  is  one  embolus,  there  may  be 
many ;  and  the  surgeon  may  reach  one  focus  of  the 
disease  and  leave  the  rest.  Or  there  may  be  only  one 
embolus,  but  this  so  large  that  a  great  part  of  the  lung 
perishes.  Or  the  gangrene,  circumscribed  for  a  time, 
may  later  become  diffused ;  or,  even  after  operation,  it 
may  continue  to  spread. 

Then,  again,  the  difificulties  of  diagnosis  may  be 
almost  insuperable.  They  may  be  gathered,  some  of 
them,  from  the  following  cases- : — 

1.  A  woman,  aged  23,  was  attacked  by  bronchitis,  with 
foetid  expectoration,  in  November,  1880.  In  December, 
there  were  signs  of  solidification  of  the  upper  lobe  of  the 
left  lung-  in  front,  with  tenderness  on  percussion,  but  no 
redness  or  swelling.  On  January  4th,  i88i,  there  were  signs 
of  pleurisy  over  the  left  base  ;  and,  about  the  middle  of  the 
month,  percussion  over  the  fourth  left  space  gave  a  cracked- 
pot  sound,  and  gurgling  was  heard  here  ;  the  pleurisy  was 
diminished.  Exploratory  puncture  in  two  places  drew  off 
two  kinds  of  fluid  :  above  and  in  front,  it  was  purulent  and 
foetid  ;  below  and  behind,  it  was  clear  and  serous.  It  thus 
appeared  that  there  was  a  gangrenous  cavity,  with  pleural 
effusion,  and  a  barrier  of  adhesions  between  them.  The 
puncture  into  the  cavity  left  a  fistulous  track,  and  the 
patient's  condition  remained  bad  :  on  January  24th,  the 
cavity  was  freely  incised,  and  a  few  ounces  of  foetid  pus 
let  out.  Slight  haemoptysis  occurred  that  evening,  and  again 
a  few  days  later.     She  made  a  complete  recovery. 

2.  A  patient,  after  pneumonia,  had  empyema,  and  under- 
went the  usual  operation  ;  but  his  temperature  remained 
high,  and  no  reason  for  this  could  be  found,  till  the  surgeon 

^  Trousseau,  vol.  v.,  p.  320.  "Med.  Chir.  See.  Trans."  1884,  p. 
209.  See  also  Mr.  Silcock's  case,  Embolism  from  heart  disease, 
"Path.  See.  Trans.,"  i885. 

'  Bull,  1881,  quoted  by  True;  Krecke  (1891),  and  Thue  (1891), 
quoted  by  Heydweiller ;  Koch,  "  Deutsch.  Med.  Wchnschr. " 
1882,  p.  440. 


GANGRENE    OF    THE    LUNG.  305 

one  day,  changing  the  dressings,  saw  a  dark  mass  in  the 
wound  ;  this  was  easily  removed,  and  was  a  piece  of  luny- 
tissue  more  than  two  inches  long  and  an  inch  thick. 
Improvement  at  once,  and  complete  recovery. 

3.  A  man,  37  yeai'S  old,  after  an  attack  of  acute  general 
bronchitis,  was  found  to  have  serous  effusion  in  both  pleurae. 
This  was  followed  by  a  circumscribed  patch  of  gangrene  in 
the  anterior  upper  part  of  ihe  right  lung.  Pieces  of  the  third 
and  fourth  ribs  were  resectecl,  and  the  lung,  which  was 
adherent  only  here  and  there,  was  stitched  to  the  chest-wall. 
The  gangrenous  cavity  was  opened  with  a  Paquelin's  cau- 
tery ;  no  irrigation  was  employed.  For  four  weeks,  the 
patient  did  well,  and  was  free  from  fever,  then  came  an 
empyema,  on  the  same  side  as  the  disease  in  the  lung  :  this, 
too,  was  successfully  treated,  and  he  made  a  good  recovery. 

4.  A  man,  24  years  old,  who  had  suffered  synovial  disease 
of  the  knee  joint  in  his  boyhood,  and  gone  through  '  a 
series  of  pneumonias,'  began,  in  1878,  to  be  troubled  with 
profuse  expectoration,  shortness  of  breath,  loss  of  flesh,  and 
severe  night-sweats.  In  1882,  there  were  signs  of  chronic 
bronchitis  about  the  upper  lobe  of  the  light  lung,  and  of  a 
cavity  in  its  lower  lobe,  with  pleural  effusion  ;  the  sputa 
were  gangrenous.  After  puncture,  on  two  occasions,  for  the 
relief  of  the  effusion,  part  of  the  sixth  rib  was  resected,  on 
June  24th  ;  the  lung  was  incised  with  a  Paquelin's  cautery, 
and  a  cavity  was  opened,  about  the  size  of  a  hen's  egg, 
lying  three  fingers'  breadth  from  the  surface.  A  week  later, 
as  the  expectoration  was  still  profuse,  a  piece  of  the  eighth 
rib  was  removed,  and  the  cautery  was  passed  53  inches  into 
the  lower  lobe  of  the  lung  ;  it  opened  only  some  small  bron- 
chial dilatations.  Further  exploration  with  a  Pravaz  syringe, 
drew  off  some  foetid  sero-purulent  fluid,  but  no  cavity  was 
found  anywhere.  On  July  nth,  a  third  operation  was  per- 
formed, and  the  lung  was  explored  through  the  eighth  space, 
between  the  scapula  and  the  spine,  but  still  without  success. 

These  four  cases  show  only  a  part  of  the  difficulties 
that  may  attend  the  diagnosis  and  treatment  of  gangrene 
of  the  lung.  It  is  pleasant  to  turn  to  the  statistics  of 
operation  for  its  relief.  The  deaths  from  the  disease 
left  to  itself  may  be  put  at  75  or  80  per  cent;  and, 
although  it  is  of  course  only  the  more  favourable  cases 
that  come  to  operation,  yet  the  saving  of  life  by  it  is 

20 


3o5  SURGERY    OF    THE    CHEST. 

past  all  dispute.  True  gives  13  operations  (1879-1884): 
3  patients  were  cured,  2  relieved,  2  were  on  the  way 
to  recovery,  and  6  died.  Hofmokl  (1892)  gives  24 
operations,  all  his  own,  with  7  cures ;  and  Heydweiller 
gives  40  (1879-1892)  with  22  cured,  4  improved,  and  14 
deaths.  The  figures  for  the  last  few  years  are  better  than 
those  for  the  years  before  them.  Reclus  gives  14 
operations  (1885 -1895),  "^^i^h  11  cured,  i  improved, 
and  only  2  deaths.  It  would  be  hard  to  find  a  more 
vivid  instance  of  good  surgery. 

Supposing  that  a  case  has  been  rightly  diagnosed  as 
one  of  gangrene  of  the  lung,  circumscribed,  accessible, 
we  have  next  to  consider  the  question.  Shall  the  operation 
be  done  at  once,  or  can  any  advantage  come  of  waiting? 

Three  reasons  are  given  why  the  surgeon  should  wait 
for  a  time,  so  long  as  there  are  no  marked  signs  of  septic 
absorption.  The  first  is,  that  he  must  not  operate  till 
the  gangrene  has  passed  the  stage  of  consolidation,  and 
become  deliquescent ;  the  second,  that  he  must  be  sure 
that  adhesions  are  present;  the  third,  that  some  cases  get 
well  of  themselves.  Now  we  may  admit  that  if  ever  the 
surgeon  finds  a  case  of  gangrene  of  the  lung  where  there 
are  no  signs  of  septic  absorption,  that  case  may  get  well 
of  itself;  but  such  a  case  is  not  likely  to  occur.  As 
for  the  stage  before  deliquescence,  the  diseased  tissue 
has  probably  deliquesced  long  before  its  existence  was 
diagnosed.  The  presence  of  adhesions  is  of  very  great 
importance ;  but  even  if  they  be  absent,  the  operation 
may  yet  be  successful,  as  we  see  from  the  third  case  of 
those  just  quoted,  and  from  Krause's  case  given  in  Reclus' 
paper,  in  the  Appendix  to  this  book.  And,  if  the  surgeon 
waits,  the  disease  may  become  more  diffused,  or  may 
break  into  the  pleura ;  as  in  a  case  of  Hofmokl's,  a  man, 
aged  30,  a  drunkard,  who,  after  acute  pneumonia,  a  month 


GANGRENE    OF    THE    LUNG.  307 

before  admission  to  Hospital,  had  gangrene  of  the  upper 
lobe  of  the  right  lung,  which  broke  into  the  pleura. 
Incision  in  the  sixth  space,  in  the  axillary  line,  let  out 
no  less  than  seven  pints  of  foetid  pus.  He  died  of 
exhaustion,  a  fortnight  after  the  operation. 

Given  then,  clear  signs  of  a  gangrenous  cavity  in  the 
lung,  as  accurately  localised,  by  careful  examination, 
as  is  possible,  and  not  drained  by  the  air-passages, 
by  what  method  shall  the  surgeon  operate  ?  He  must, 
of  course,  make  an  exploratory  puncture ;  and  he  had 
better  be  prepared  to  follow  this  at  once  by  operation, 
if  he  find  pus  ;  though  I  do  not  know  of  any  case  of 
gangrene  where  puncture  with  a  fine  needle  has  infected 
the  pleura.  His  incision  must  be  free,  and  he  must  not 
hesitate  to  resect  a  piece  of  a  rib,  or  even  of  more 
than  one  rib,  if  the  cavity  be  of  great  size.  But  many 
cases  of  recovery  have  been  recorded  after  simple  punc- 
ture of  the  cavity  with  a  large  trochar  and  cannula, 
followed  by  drainage.  At  all  events,  there  is  no  clear 
evidence  in  favour  of  the  '  preliminary  Estlander's 
operation,'  which  is  advocated  by  one  or  two  surgeons 
as  the  first  step  toward  opening  and  emptying  a  large 
cavity  in  the  lung. 

Of  the  importance  of  finding  or  establishing  adhesions, 
something  has  already  been  said  in  the  chapter  on 
'Abscess  of  the  Lung,'  and  more  will  be  found  in  Reclus' 
paper.  If  the  question  be  not  determined  by  the  oscil- 
lation or  non-oscillation  of  a  needle  passed  into  the  lung, 
the  surgeon  may  settle  it  by  carefully  exposing  the  pleura 
without  opening  it.  If  it  be  thin  and  half-transparent, 
and  the  lung  be  visible  moving  up  and  down  beneath  it, 
there  are  no  adhesions.  He  must  then,  if  the  case  be  not 
very  urgent,  fasten  the  lung  to  the  pleura,  and  wait  a 
day  or  two  (Reclus  says  five  days  at  least)  before  opening 


308  SURGERY    OF    THE    CHEST. 

it.     But  if  he  cannot  wait,  or  cannot  secure  the  lung  to 

the  pleura  without  opening  the  latter,  he  must  do  this, 

and  stitch  the   two    together,   as    in    operating   on  the 

liver. 

Roux's    method  of  suture,    '  k   arriere-point,'  is   best 

described  in  his  own  words. ^ 

"  Having  incised  the  intercostal  muscles,  exposed  the 
pleura,  and  seen  the  lung  moving  freely  beneath  it,  I  sutured 
the  two  layers  of  the  pleura  together,  all  round  the  wound, 
catching  up  the  lung  tissue  with  a  curved  needle  as,  during 
each  inspiration,  it  came  forward  into  the  wound.  But 
instead  of  simply  putting  separate  points  of  suture  here  and 
there,  and  thus  leaving  gaps  which  might  admit  air,  I  did 
what  the  women  in  my  part  of  the  country  call  '  suture  k 
arri^re-point '  :  the  needle  is  passed  through  the  pleura,  picks 
up  the  lung,  and  comes  out  again  through  the  pleura  ;  then 
it  is  put  through  again,  between  the  points  of  entrance  and  of 
exit,  picks  up  the  lung  again,  comes  out  in  front  of  the  first 
point  of  exit,  and  so  on :  thus  you  get  a  continuous  suture  all 
round,  and  finish  by  tying  its  two  ends  together.  It  keeps 
the  two  layers  of  the  pleura  in  perfect  apposition,  and  yet 
there  is  no  dragging  on  it  ;  so  that  you  avoid  the  little 
lacerations  and  gaps  that  you  get  with  an  interrupted  suture. 
I  used  it  six  days  ago,  in  a  case  of  cavity  in  the  apex  of  the 
right  lung  in  front,  not  adherent,  and  opened  the  cavity  at 
once.  It  has  held  perfectly  ;  not  a  bubble  of  air  has  entered 
the  pleura,  the  patient  has  lost  his  fever,  and  is  already  able 
to  leave  his  bed."' 

If  the  surgeon,  having  got  down  to  the  pleura,  should 

find  no  adhesions,  he  may  yet  learn  something  by  feeling 

the  lung  through  it  without  opening  it.     The  following 

observation  by  Tuffier-  is  of  interest,  but  the  manoeuvre 

needs  practising  on  the  dead  body. 

"  I  had  occasion  not  long  ago  to  find  out  the  practical 
value  of  stripping  the  parietal  pleura  oft'  the  ribs.  The  case 
was  one  of  gangrene  of  the  lung.     I  made  my  incision  over 

'  "  D'un  nouveau  precede  applicable  aux  interventions  sur  le 
poumon."  Roux  (de  Lausanne),  See.  de  Chir.,  Paris,  June  17, 
1891. 

-  "  Semaine  Medicale,"  1891,  p.  202. 


GANGRENE    OF    THE    LUNG.  309 

the  place  where  the  physical  signs  of  a  cavity  had  been 
observed,  and  resected  a  piece  of  the  eighth  rib,  and  then 
loosed  the  pleura  from  the  ribs  over  an  area  of  four  or  five 
fingers'  breadth.  It  was  easy  to  palpate  the  lung  through 
it,  and  I  could  feel  nothing  abnormal  anywhere.  I  therefore 
went  on  loosing  the  pleura  off  the  ribs,  and  at  last  I  made 
out  an  area  of  induration  in  the  lung,  and  gained  easy  access 
to  it  by  further  resection  of  the  rib.  At  this  point  there  were 
adhesions.  I  made  my  incision  through  the  pleura  here, 
opened  the  cavity,  and  let  out  a  quantity  of  pus.  I  washed 
and  drained  the  cavity ;  the  temperature  came  down,  and  the 
patient  is  doing  well.  In  cases  of  this  kind,  therefore,  if 
you  don't  come  straight  down  on  the  disease,  you  can,  I 
think,  by  thus  raising  the  pleura  oft"  the  ribs,  find  the  gan- 
grenous focus  without  opening  the  pleura  to  do  it.  You 
must  begin  working"  at  the  pleura  in  an  intercostal  space,  as 
it  is  looser  here  than  at  the  upper  and  lower  borders  of  the 
ribs.^ 

If  the  surgeon,  after  the  cavity  has  been  accurately 
localized  before  operation,  shotild  yet  be  in  doubt  as  to 
the  exact  point,  to  an  inch  one  way  or  the  other,  where 
to  place  his  skin-incision,  he  should  remember  that  the 
disease  tends  to  track  downward,  and  that  he  had  better 
go  too  low  than  too  high.  Not  that  it  matters  much,  so 
far  as  the  healing  of  the  cavity  is  concerned,  where  it  is 
opened  ;  for  it  is  healed  by  a  sort  of  concentric  process 
ot  contraction ;  but  if  he  cannot  be  sure  of  hitting  the 
centre  of  the  cavity,  he  had  better,  in  view  of  the  down- 
ward tendency  of  the  disease,  be  below  this  point  than 
above  it.^ 

'  We  must  note  that  this  '  decollement '  of  the  pleura  was  used 
by  Tuf&er  in  his  case  of  resection  of  the  apex  for  tubercular 
phthisis.  Trying  it  on  the  dead  body,  I  find  that  one  must  go 
very  slowly,  keeping  the  back  of  one's  finger  toward  the  pleura. 

^  '  The  gangrenous  patch  is  generally  considerably  below  the 

level  at  which  the  signs  of  a  cavity  are  found I  wish  to 

point  out  the  rapidity  with  which  the  gangrenous  process  extends 
downward  from  the  cavity  at  the  root  of  the  lung  (in  suppuration 
of  the  bronchial  glands),  and  hence  the  necessity  for  an  opening 
low  down.'  Voelcker :  for  reference  see  chapter  on  '  Inflamma- 
tion of  Bronchial  Glands.' 


3IO  SURGERY    OF    THE    CHEST. 

The  method  of  opening  the  cavity  must  depend  on 
the  depth  at  which  it  hes.  The  cavity  may  be  superficial 
as  in  J^/afe  IX.,  and  may  be  incised  without  risk  of 
hsemorrhage.  But  if  it  be  in  the  depths  of  the  lung, 
from  evidence  given  by  the  physical  signs  and  by  ex- 
ploratory puncture,  it  is  safer  to  use  a  Paquelin's  cautery, 
advancing  very  slowly  through  the  lung-tissue.  There 
are,  of  course,  advantages  in  a  free  opening  into  the 
cavity ;  but  good  results  have  been  obtained  by  the  use 
of  the  trochar  and  cannula  alone.  It  was  successful  in 
the  following  case,^  perhaps  the  deepest  cavity  on  record. 

A  woman,  aged  23,  during  the  extraction  of  some  stumps 
of  teeth,  in  February,  1887,  let  one  of  them  slip  into  her 
air-passages,  and  a  few  days  later  began  to  have  a  trouble- 
some cough,  with  slight  muco-purulent  expectoration.  This 
went  on  for  four  months,  and  she  gradually  lost  strength. 
By  June  she  was  feverish,  sleepless,  with  paroxysms  of  cough 
lasting  several  hours  ;  sputa  offensive  and  very  profuse ; 
coarse  rales  over  central  pait  of  right  lung,  some  dulness  at 
its  base,  some  tenderness  on  percussion  in  front.  By  July, 
she  was  exhausted  with  incessant  cough,  hectic  fever,  bed- 
sores, aphthous  ulceration  of  the  mouth  :  two  or  three  pints 
of  foetid  pus  were  coughed  up  daily,  it  ran  from  her  mouth 
during  sleep,  and  particles  of  cartilage  and  lung-tissue  were 
found  in  it.  Amphoric  breathing,  with  metallic  tinkling,  was 
heard  toward  the  centre  of  the  lung,  over  a  space  of  more 
than  four  square  inches.  Operaifwn,  July  i8th:  the  needle 
of  an  aspirator  was  pushed  its  full  length  into  the  chest, 
through  the  ninth  space,  an  inch  behind  the  axillary  line,  and 
found  pus.  It  was  withdrawn,  and  a  large,  curved  trochar 
and  cannula  were  passed  in  the  same  direction,  upward  and 
forward  toward  the  sixth  space  in  front,  and  foetid  pus  flowed 
in  great  quantity.  A  drainage-tube  was  passed  down  the 
cannula,  and  was  not  withdrawn  till  the  thirty-second  day. 
The  patient  recovered  completely.  'The  pus  was  not 
reached  until  about  seven  inches  had  been  traversed  by  the 
trochar  ;  and  there  had  been  no  pleurisy  capable  of  gluing 
the  two  surfaces  together.    Both  auscultation  and  percussion 

'  Dr.  Strange,  "Brit.  Med.  Journ."  1S87,  p.  1145. 


Plate  ix. 


Gangrene  of  the  Lung ;  a  large  superficial  circumscribed  cavity,  in  need  of 
operation.     (From  a  specimen  in  the  Royal  College  of  Surgeons'  Museum.) 


GANGRENE    OF    THE    LUNG.  311 

pointed  to  the  presence  of  a  considerable  layer  of  sound 
lung  between  the  pleura  and  the  abscess-wall,  which  layer 
was  at  least  several  inches  thick.  The  absence  of  bleeding 
at  the  operation,  and  of  effusion  of  air  or  pus  into  the  pleural 
cavity,  1  attribute  to  the  resiliency  of  the  healthy  portion  of 
the  lung,  and  the  pressure  exerted  by  the  closely-fitting  piece 
of  elastic  tubing  which  was  inserted  immediately  aiter  the 
pus  had  been  evacuated'.' 

The  next  two  cases-  relate  to  the  removal  of  the  gan- 
grenous tissues  :  the  first  of  them  is  also  an  argument  in 
favour  of  free  incision.  As  to  removal  of  the  walls  of 
the  cavity,  Delageniere,  who  reported  the  second  case, 
admits  that  he  does  not  find  any  evidence  that  it  is 
much  bettter  than  simple  free  incision. 

I.  A  man,  aged  63,  a  year  after  acute  bronchitis,  which 
left  a  persistent  cough,  began  to  have  purulent  expectora- 
tion ;  then  came  sharp  pain  in  the  upper  part  of  one  side  of 
the  chest,  in  front ;  dulness,  loss  of  vocal  vibi-ation  down  to  the 
third  rib,  breath-sounds  feeble,  blood-stained  sputa.  A  month 
later,  a  painful  spot  was  noted  beneath  the  clavicle,  and  this 
was  followed  by  fluctuation  and  emphysema.  Incision  here 
let  out  foetid  air  and  pus  from  beneath  the  pectoral  muscle  ; 
a  small  opening  was  made  into  the  chest,  admitting  a 
drainage  tube.  No  improvement  ;  two  months  later,  his 
condition  seemed  hopeless.  The  wound  was  now  laid  open, 
a  piece  of  the  third  rib  was  resected  ;  the  upper  lobe  of  the 
lung  was  found  to  be  gangrenous,  and  the  whole  of  the  apex 
was  scraped  away  with  the  finger  and  the  handle  of  the 

'  We  may  contrast  with  this  case  what  Hofmokl  (1892)  says  of 
one  like  it.  '  In  a  case  of  gangrene  of  the  lung  from  a  piece  of 
bone  passing  into  the  bronchus,  I  abstained  from  operating, 
because  it  was  impossible  exactly  to  localize  the  foreign  body, 
and  because  there  was  a  considerable  thickness  of  healthy  lung- 
tissue  around  the  disease.  There  would  have  been  haemorrhage 
(as  the  post  mortem  examination  showed),  which  would  have  pre- 
vented our  finding  the  foreign  body.  Yet  it  is  possible  that  even 
if  free  incision  of  the  lung  failed  to  find  it,  the  foreign  body  might 
at  a  later  period  be  discharged  or  removed  along  the  track  of  the 
drainage-tube.' 

^  Urinkwater,  "  Lond.  Med.  Rec,"  May  15,  1884.  Dela- 
geniere,  "  Cong.  Franc,  de  Chir."  Paris,  1892. 


312  SURGERY    OF    THE    CHEST. 

scalpel.     Drainage  and  irrigation  were  used,  and  a  tube  was 
kept  in  for  six  months.     Complete  recovery. 

2.  A  man,  aged  27^  presented  the  signs  of  a  large  gan- 
grenous cavity  at  the  base  of  the  left  lung.  A  very  extensive 
operation  was  performed,  with  a  long  curved  incision,  and 
subperiosteal  resection  of  eighth,  ninth,  and  tenth  ribs,  from 
their  angles  to  their  cartilages;  the  incision  through  the 
pleura,  along  the  line  of  the  ninth  rib,  was  six  inches  long. 
A  large  cavity  was  laid  open,  between  the  diaphragm  and 
the  gangrenous  lower  lobe  of  the  lung,  and  fifteen  cr  sixteen 
ounces  of  foetid  pus  and  deb7-is  were  let  out.  The  whole 
gangrenous  portion  of  the  lung  was  removed  with  forceps 
and  scissors,  and  a  cavity,  the  size  of  one's  fist,  was  left;  this 
was  carefully  cleansed  and  irrigated.  Drainage  for  a  month  ; 
complete  recovery  in  six  weeks. 

Counter-opening  has  been  made  in  a  few  cases,  and  it 
is  certain  that  the  cavity  should  be  very  freely  drained, 
as  blocking  of  the  tube,  and  retention  of  septic  debris, 
have  been  noted  in  more  than  one  case.  And  the 
drainage  should,  as  a  rule,  be  kept  up  for  many  weeks, 
or  even  for  months,  till  it  is  certain  that  the  cavity  has 
closed.  Irrigation  has  been  used  in  nearly  every  case. 
In  one  or  two  it  has  caused  troublesome  cough  or  slight 
haemoptysis,  and  one  or  two  more  have  done  very  well 
without  it ;  but  the  weight  of  evidence  is  in  favour  of  it. 
But  I  do  not  think  it  should  be  done  immediately  after 
the  operation,  while  the  patient  is  still  under  the  influence 
of  the  ancesthetic. 

Finally,  there  are  cases  where  the  operation  failed; 
but  we  must  note  that  an  apparent  failure  may  yet  be 
successful,  as  in  the  following  instance ^ : — 

A  girl,  8  years  old,  after  necrosis  of  the  left  mastoid  from 
scarlet  fever,  had  symptoms  of  gangrene  of  the  lung,  and 
finally  gave  signs  of  a  large  cavity  at  the  base  of  the  right 
lung.     An  aspirating  trochar  and  cannula  were  passed  in- 

'  Dr.  Cayley  and  Mr.  Pearce  Gould.  A  casa  of  gangrene  of 
the  lung,  following  necrosis  of  the  temporal  bone.  "  Med.  Chir. 
Soc.  Trans."  1884,  p.  208, 


GANGRENE    OF    THE    LUNG.  313 

ward  and  upward,  through  the  eighth  space  about  an  inch 
outside  the  angle  of  the  rib.  A  few  drops  of  foetid  pus  came 
out,  and  air  passed  in  and  out  with  the  movements  of  respi- 
ration. A  large  trochar  and  cannula  were  then  passed  in 
the  same  direction,  but  there  was  no  further  escape  of  either 
pus  or  air.  A  drainage  tube  was  inserted  ;  next  day,  a  little 
foetid  pus  came  through  the  tube,  and  air  passed  out  on 
expiration.  Next  day,  the  dressings  were  soaked  with  foetid 
pus,  and  a  slough  of  lung-tissue  was  found  in  the  tube.  For 
some  days,  the  discharge  was  profuse :  the  tube  was  removed 
very  early,  eighth  day.    She  made  an  uninterrupted  recovery. 

The  real  failures  seem  due  mostly  to  delay  before  the 
operation,  or  to  ultimate  extension  of  the  disease  in 
spite  of  it.  In  one  case,  the  gangrene  reached  the  chest- 
wall,  spread  far  and  wide  among  the  muscles,  and  thus 
brought  about  death.  In  another,  the  patient  died  of 
cerebral  abscess.  I  can  find  no  record  of  entire  failure 
to  find  the  disease  at  the  time  of  operation.  There  is 
no  need  to  quote  a  longer  list  of  cases  :  those  given  are 
enough  to  show  that  the  risks  and  difficulties  of  the 
operation  are  not  to  be  compared  with  the  saving  of  life 
it  has  achieved. 

Dr.  Perry  ("Path.  Soc.  Trans.,"  1893)  has  recorded 
a  case  of  death  from  haemorrhage  from  gangrene  after 
pneumonia.  The  patient,  a  man  aged  45,  died  the  day 
after  admission  to  Hospital:  52  ounces  of  blood  were 
found  in  the  pleura. 


314 


CHAPTER  XXI. 

TUBERCULAR  PHTHISIS. 

It  is  difficult  to  estimate  the  results  of  the  operations 
that  have  been  done  in  these  cases.  So  far  as  I  can  see, 
it  is  not  fair  to  say  that  the  successes  have  been  published, 
but  not  the  failures^ ;  on  the  contrary,  the  list  of  the  un- 
successful operations  is  a  very  long  one.  It  would  be 
just  as  reasonable  to  observe  that  many  phthisical  patients 
have  died  unrelieved,  whose  sufferings  might  have  been 
alleviated  if  the  surgeon  had  been  allowed  to  operate 
upon  them.  Nor  are  these  methods  now  advocated  with 
any  excess  of  commendation  ;  indeed,  the  tendency  is 
toward  retreat  rather  than  advance.  I  shall  only  attempt 
to  give  some  account  of  what  has  already  been  done  in 
this  field  of  surgery  here  and  abroad,  and  to  show  how 
little  hope  we  have  at  present  of  doing  better.-  But  we 
must  remember  that  even  to  relieve  the  suffering  of  the 
last  few  weeks  of  phthisis  is  itself  a  successful  operation, 
and  that  there  is  no  real  difference  between  saving  life 
and  delaying  death  ;  and  it   seems  to  me  that  Reclus  is 

'For  example,  nothing  could  be  more  unfair  than  Bouchut's 
bombastic  condemnation  of  the  operation  in  the  Hastings- 
Storks  case  (1844)  •  '  ^  reckless  physician  or  surgeon  is  much 
the  same  all  the  world  over,  whether  in  France  or  in  England  ; 
so  soon  as  they  have  begun  to  grasp  some  audacious  idea,  they 
make  haste  to  publish  the  first  bulletins,  leaving  to  others  the 
work  of  hiding  the  last  bulletin  in  the  dust  of  the  grave ;  and 
thus  they  hope,  but  in  vain,  to  advance  themselves,  cheat  science, 
and  hoodwink  the  profession.' 

-  The  references  to  experiments,  and  to  some  of  the  operations, 
are  from  True  and  Reclus. 


TUBERCULAR    PHTHISIS.  315 

inclined  to  undervalue  the  alleviation  of  distress  that  may 
be  gained  in  some  of  these  cases  by  surgical  treatment.^ 

The  methods  of  surgery  possible  for  tubercular  phthisis 
are  five  in  number :  Injection  of  fluids  into  the  lung- 
tissue  ;  operation  for  pyo-pneumothorax  with  perforation 
of  the  lung  ;  operation  for  the  arrest  of  profuse  hccmo- 
ptysis;  resection  of  the  apex  of  the  lung;  and  incision  of 
a  tubercular  cavity.  We  may  take  these  five  subjects  in 
this  order,  and  follow  the  evidence  for  and  against  each 
of  them. 

I. — Injections  into  the  Lung  Tissue. 

This  treatment  of  tubercular  phthisis  has  received  a 
fair  trial  during  the  last  ten  years ;  but  I  believe  it  has 
never  found  favour  in  England.  The  experiments  which 
preceded  it  showed  clearly  that  it  is  possible  by  this 
method  to  cause  wide-spread  cicatricial  changes  in  lung- 
tissue  without  doing  harm.  Twenty  years  ago,  W.  Koch 
and  Konig  made  numerous  injections  of  sodium  iodate 
and  of  iodine  into  the  lungs  of  animals,  and  were  able, 
without  any  bad  results,  to  convert  large  tracts  of  the 
lung  into  cicatricial  tissue.  In  1882,  Frankel  tried  many 
different  substances — alum,  carbolic  acid,  boracic  acid, 
iodoform,  but  without  any  very  marked  results  ;  in  1885, 
True  and  Lepine  used  creasote,  corrosive  sublimate,  and 

^  'Picture  to  yourself  that  most  distressing  condition,  the  final 
stage  of  chronic  phthisis.  See  your  worn  and  attenuated  patient, 
longing  for  sleep,  tossing  restlessly  from  position  to  position, 
struggling  incessantly  with  a  cough  that  sets  rest  and  repose 
perpetually  at  defiance  :  see  the  reeking  transparent  skin,  the 
saturated  hair,  and  the  piteous  expression  of  weariness  and  utter 
exhaustion — and  say  whether  such  relief  as  might  be  obtained 
from  an  outlet,  through  which  all  this  horrible  corruption  might 
be  extruded,  might  not  be  worth  the  additional  risk  of  even  a 
somewhat  serious  operation. ' — Wheelhouse,  "Brit.  Med.  Journ.," 
1887,  ii.,  1141, 


3i6  SURGERY    OF    THE    CHEST. 

alcohol,  and  with  these  produced  more  definite  inflam- 
mation and  exudation,  without  suppuration  or  bad  effects 
of  any  kind. 

But  what  is  the  evidence  as  to  the  practical  value  of 
this  method  for  the  relief  or  cure  of  a  phthisical  patient  ? 
We  may  best  answer  this  question,  if  we  first  consider 
the  general  objections  that  are  opposed  to  it,  and  then 
take  the  experience  of  those  who  have  made  a  fair  trial 
of  it. 

Certainly  this  treatment  by  injections,  if  we  are  to 
accept  it,  must  win  acceptance  by  its  own  merits,  and 
must  stand  the  test  of  practical  use ;  for  there  is  nothing 
else  to  commend  it  to  us,  and  it  is  a  way  of  working 
in  the  dark  which  recalls  Voltaire's  accusation  against 
the  physicians  of  his  own  day,  that  they  were  putting 
drugs  of  which  they  knew  little  into  bodies  of  which  they 
knew  less.  The  number  of  the  remedies  that  have  been 
tried — permanganate  of  potash,  carbolic  acid,  salicylic 
acid,  iodine,  nitrate  of  silver,  creasote,  perchloride  and 
biniodide  of  mercury — shows  that  the  right  one  is  still 
not  found ;  nor  do  we  know  how  far  the  desired  result 
is  simple  scarring  of  the  diseased  lung  tissue,  and  how 
far  it  is  the  arrest  or  destruction  of  the  bacilli  th-em- 
selves.  To  expect  to  do  much  for  phthisis  with  a  few 
drops  of  antiseptic  fluid,  driven  haphazard  once  or  twice 
a  week  into  a  lung  which  we  know  to  be  tubercular,  but 
cannot  know  the  exact  extent  and  distributian  of  the 
disease,  is  surely  to  ignore  the  plain  teaching  of  pathol- 
ogy i.     We  are  told  that  the  w^hole  hope  of  this  method 

^  '  Let  me  draw  your  attention  to  one  point  concerning  injec- 
tions into  the  lung-tissue  in  cases  of  tubercular  phthisis. 
Pulmonary  tuberculosis,  with  its  multiple  scattered  foci  of 
disease  in  a  vital  organ,  is  the  worst  possible  field  for  this  kind 
of  treatment.  In  local  tuberculosis  of  peripheral,  easily  accessible 
tissues,  such  as  the  skin,  the  bones,  and  the  joints,  we  have  of 


TUBERCULAR    PHTHISIS.  317 

is  in  getting  the  case  at  an  early  stage  of  the  disease  ; 
but  we  have  no  clear  evidence  that  even  thus  the  mjec- 
tions  are  of  much  value.  And  when  we  consider  that 
those  who  suffer  from  phthisis  are  apt  to  hope  against 
hope,  we  shall  find  reason  to  discount  the  improvement 
which  they  have  noted  in  themselves  after  this  treat- 
ment. 

What  then,  apart  from  theoretical  objections,  is  the 
actual  result  of  this  method  in  practical  use  ?  We  are 
not  here  concerned  with  the  treatment  of  phthisis  by 
hypodermic  medication, ^  but  with  the  injection  of  fluids 
into  the  diseased  area  of  the  lung.  Can  we  find  any 
records  of  success  to  contradict  the  unfavourable  opinion 
given  in  the  latest  English  text-book  on  this  subject  ?" 
I  have  not  found  anything  of  the  kind,  and  there  are 
plenty  of  instances  of  failure,  and  of  harm  done  instead 
of  good.  The  worst  results  have  come  from  the  use  of 
the  biniodide  of  mercury,  as  might  be  expected  ;  it  has 
caused  acute  suppurative  bronchitis,  ending  in  death  in 
24  hours,  acute  pleurisy,  and  other  troubles.  Riva^  had 
a  case  of  fatal   cerebral   embolism,   occurring  during  the 


course  the  best  opportunity  for  the  local  application  of  germicidal 
remedies.  Prove  the  efficacy  of  your  substances  first  on  these 
parts  of  the  body,  before  you  go  on  to  experimenting  on  the  lungs 
with  them.' — ]^enzoldt,  "Verhandl.  des  Congr.  f.  Inn.  Med.,"  1S85- 
6,  p.  58. 

^  A  full  account  of  this  treatment  is  given  in  Harris  and  Beale's 
recent  work,  "  The  Treatment  of  Pulmonary  Consumption," 
London,  1895.  They  draw  attention  to  the  good  results  obtained 
by  Opitz  (1889)  from  the  use  of  balsam  of  Peru,  and  by  Roussell 
(1888)  from  eucalyptol. 

'^  'We  may  say  that  so  far  no  results  sufficiently  good  to  justify 
the  great  discomfort,  which  is  certain,  and  the  risk  of  fatal  com- 
plications, which  is  possible  to  result  from  these  injections,  have 
been  recorded.'     Harris  and  Beale,  loc.  cit. 

3  For  reference,  see  Heydweiller's  excellent  inaugural  disser- 
tation "  Ueber  Lungenchirurgie,"  Berlin,  1894. 


3i8  SURGERY    OF    THE    CHEST. 

injection.  Lesser  troubles  are  of  frequent  occurrence ; 
For  example,^  25  injections  of  creasote,  divided  among 
15  patients,  gave  rise  to  the  following  long  list  of  slight 
disturbances ;  in  5,  slight  pain  ;  in  5,  severe  pain ;  in  2, 
severe  cough  ;  in  3,  a  slight  touch  of  pneumonia  ;  in  4, 
slight  emphysema;  and  in  6,  slight  fever.  Serious  troubles 
are  rare  :  for  example,  Pepper,  of  New  York  (1885)  made 
282  injections  among  17  patients,  without  a  single  disas- 
ter of  any  kind ;  but  also  without  any  very  marked 
results.  One  looks  in  vain  for  any  list  of  cures  ;  there 
are  plenty  of  cases  of  slight  improvement,  and  that  is  all. 
Of  course  it  is  possible  that  if  this  treatment  were  more 
generally  used,  and  limited  to  cases  in  the  first  stage  of 
the  disease,  some  more  definite  measure  of  success  would 
be  gained  ;  but  as  things  are  at  present  we  can  hardly 
desire  that  it  should  be  kept  from  falling  into  oblivion. 

2.- — Operation    for    Pyo-pneumothorax    with 
Perforated   Lung. 

This  subject  has  been  already  mentioned  in  the  chap- 
ter on  'Empyema';  and  here  we  have  to  consider  it  again, 
on  account  of  a  few  recent  operations  which  have  gone 
so  far  as  to  expose  and  suture  the  perforation  in  the 
lung.     The  state  of  the  pleura,  in  tubercular  phthisis. 


'  Truc's  cases.  He  used  a  solution  of  creasote  in  alcohol,  i  in 
25,  or  1  in  50.  Most  of  the  patients  had  only  one  injection  ;  some 
had  two,  three,  or  four,  at  intervals  varying  from  a  few  days  to 
several  weeks  ;  the  injection  was  made  very  slowly,  through  one  of 
the  first  three  intercostal  spaces.  Immediately  after  it,  the  physical 
signs  were  certainly  changed,  but  in  a  few  days  they  returned  to 
their  former  character.  Some  of  the  patients  felt  better  after  the 
injections — less  cough  and  expectoration,  better  sleep  and  appe- 
tite. He  gave  relief  in  a  few  of  the  cases,  in  the  early  stage  of 
the  disease ;  he  did  not  in  a  single  advanced  case  check  its 
ordinary  course. 


TUBERCULAR    PHTHISIS.  319 

ranges  from  slight  adhesions,  which  are  ahvays  present,' 
to  foetid  pyo-pneumothorax  soon  causing  death ;  and 
West  has  shown  that  5  per  cent,  of  the  deaths  from 
phthisis  occur  soon  after  the  onset  of  pneumothorax, 
mostly  within  a  fortnight.  It  is  evident  that  one  must 
not  by  vigorous  aspiration  break  down  the  adhesions 
which  limit  the  disease,  and  thus  convert  a  simple  and 
almost  harmless  serous  effusion  into  something  much 
worse ;  and  there  is  a  good  deal  to  be  said  in  favour  of 
leaving  these  effusions  alone,  so  long  as  they  cause  no 
serious  pressure,  and  no  septic  absorption  ;  and  if  the 
effusion  is  altogether  subordinate  to  extensive  advancmg 
tubercular  infiltration  of  the  lung,  a  partial  removal  of  it 
may  be  safer  than  any  more  active  treatment. 

But  if  the  condition  of  the  pleura  is  the  worst  part  of 
the  case,  if  the  patient  is  suffering  from  a  large  foetid 
pyo-pneumothorax,  and  shows  signs  of  septic  absorption 
over  and  above  those  that  may  be  referred  to  the  disease 
in  the  lung,  then  surgery  may  do  something  to  ease  his 
distress   and   prolong  his  life.       And  the   question  has 


^ '  So  common  are  pleuritic  affections  in  phthisis  that  a  post- 
jnortem  examination  which  did  not  reveal  the  presence  of  adhesions 
in  some  part  or  other  of  the  pleura  would  be  almost  a  curiosity  ; 
in  the  records  of  100  post-mortem  examinations  on  cases  of  phthisis, 
taken  at  random  from  the  books  of  Victoria  Park  Hospital,  adhe- 
sions were  present  in  every  case  .  .  .  Effusion  is  by  no 
means  a  common  occurrence  in  phthisis  ;  out  of  100  cases  taken 
from  the  post-mortem  records  of  the  same  Hospital,  in  g  only  was 
there  effusion,  apart  from  pneumothorax  ;  in  two  of  these,  the 
fluid  was  blood-stained,  in  the  others  it  was  clear  ;  and  in  associa- 
tion with  pneumothorax  there  were  seven  cases  of  effusion,  i 
purulent,  i  clear,  3  turbid,  and  2  blood-stained.  ...  In  the 
large  majority  of  phthisical  cases,  in  which  pneumothorax  takes 
place,  some  amount  of  fluid  effusion  ensues  ;  and  the  presence  of 
tubercle  bacilli  may  often  be  demonstrated  in  it.  It  is  usually 
milky  or  semi-purulent  in  appearance,  but  rarely  serous ;  in  some 
cases  pus  may  be  very  soon  poured  out,  and  this  may  become 
offensive.' — Harris  and  Beale,  loc.  cit. 


320  SURGERY    OF    THE    CHEST.     . 

lately  been  raised,  whether  the  surgeon  would  be  justified 
in  attempting,  instead  of  simple  incision,  to  expose  the 
lung  freely,  in  the  hope  of  being  able  to  close  the  per- 
foration in  it. 

In  1893,  ^^^-  Guermonprez,  of  Lille,^  thus  operated  on 
a  boy,  aged  18,  who,  after  pleurisy,  had  pyo-pneumo- 
thorax,  with  perforation  of  the  lung ;  but  it  does  not 
appear  that  he  was  suffering  from  phthisis.  Resection  of 
the  seventh  rib  gave  free  access  to  the  fistulous  opening 
in  the  lung ;  and  it  was  closed,  without  any  refreshing  of 
its  margin,  with  catgut  sutures.  The  operation  was 
perfectly  successful. 

Last  year.  Dr.  Marchant,  of  Paris,  and  Dr.  Delageni^re, 
of  Mans,  reported  the  three  following  cases- : — 

I.  A  man,  long  suffering  from  phthisis,  was  admitted  to 
Hospital,  on  July  ^th,  1895,  with  pyo-pneumothorax  of  the 
right  side,  not  foetid,  which  had  already  been  punctured 
seven  times  in  the  last  eight  weeks.  His  breathing  was  dis- 
tressed, and  he  was  feverish,  and  altogether  in  a  very  critical 
state.  Operation.,  under  ether  ;  a  large  U-shaped  flap  of 
skin  and  muscles  was  raised  on  the  outer  and  posterior 
aspect  of  the  side  of  the  chest,  and  about  three  inches  each 
of  the  fifth,  sixth  and  seventh  ribs  were  removed  ;  the  pleura, 
which  was  nearly  half  an  inch  thick,  was  cut  away  very  freely, 
and  between  five  and  six  pints  of  pus  were  let  out.  The  lung 
was  found  shrunken  and  packed  away  against  the  spine.  On 
its  outer  aspect,  at  the  junction  of  its  middle  and  lower  thirds, 
was  a  small  round  opening  ;  an  attempt  was  made  to  draw 
the  lung  forward  and  thus  to  reach  and  suture  the  opening, 
but  the  lung  did  not  move,  and  was  so  friable  that  no  traction 
could  be  made  on  it.  The  huge  cavity  was  lightly  packed 
with  salol  gauze,  and  drained.      Three  days  after  the  opera- 


'  See  "  Wien.  Med.  Wchnschr.,"  1893,  p.  113.  It  was  observed 
that  the  opening  in  the  lung  was  widened  at  the  end  both  of 
expiration  and  of  inspiration. 

^  See  discussion  at  the  end  of  M.  Reclus'  paper.  Reference  is 
also  made  here  to  a  similar  operation,  unpublished,  performed 
last  year  by  M.  Delorme. 


TUBERCULAR    PHTHISIS.  321 

tion,  air  could  still  be  heard  passing  from  the  lung  into 
the  cavity  ;  but  on  the  sixth  day  this  had  ceased,  and  the 
opening  in  the  lung  remained  closed.  In  October,  there  was 
still  a  discharge  from  the  wound,  and  the  patient  was  weak 
and  emaciated. 

2.  A  man,  aged  45,  suffering  from  phthisis,  was  admitted 
to  Hospital  on  Dec.  loth,  1S94,  with  a  purulent  effusion  into 
the  right  pleura,  which  on  Dec.  31st  broke  into  the  air- 
passages.  He  now  began  to  cough  up  enormous  quantities 
of  fearfully  foetid  pus,  and  was  going  rapidly  from  bad  to 
worse  :  absolute  dulness  over  the  lower  two-thirds  of  the 
right  lung,  behind  and  in  the  axillary  line  ;  signs  of  softening 
of  the  left  apex  ;  constant  fever,  extreme  dyspnoea,  general 
condition  almost  hopeless.  O^erah'on,  Feb.  22nd,  1895,  under 
chloroform  ;  a  large  U-shaped  flap  of  skin  and  muscles  was 
raised  in  the  axillary  line,  from  the  fifth  to  the  tenth  rib. 
Resection  of  three  or  four  inches  each  of  the  sixth  to  ninth 
ribs,  beginning"  at  the  ninth  and  working  upward  :  free 
opening"  into  the  pleura,  disclosing  a  cavity  the  size  of  two 
fists,  extending  forward  to  the  anterior  axillary  line,  back- 
ward to  the  spine,  and  upward  out  of  reach  of  the  finger. 
Two  perforations  were  found  in  the  lung,  both  on  its  exterior 
lateral  aspect,  one  in  its  upper  half,  the  other  at  its  base '  : 
the  latter  was  scraped  and  sutured,  the  former  was  out  of 
reach  of  treatment.  An  attempt  at  irrigation  caused  such 
coughing  and  choking  that  it  had  to  be  abandoned  ;  the 
cavity  was  packed  with  gauze.  The  fever  disappeared,  the 
sputa  became  less,  and  were  no  longer  foetid  ;  he  slept 
and  ate  well.  The  perforation  that  was  not  closed  at  the 
operation  was  healed  ten  days  after  it  ;  air  was  no  longer 
heard  passing  into  the  cavity.  '  To  see  him  to-day  (Oct. 
22nd,  1895),  though  he  is  still  phthisical,  you  would  fail 
to  recognize  the  moribund  patient  on  whom  I  operated  last 
February.' 

3.  A  man,  aged  28,  was  under  treatment  in  1892  for  acute 
bronchitis,  and  later  for  tubercular  phthisis.  In  June,  1893, 
he  was  seized  with  dyspnoea  and  profuse  flow  of  pus  by  the 
mouth  ;  and  these  attacks  occurred  at  first  once  a  week,  and 
afterward  every  five  or  six  days.  The  left  lung  seemed 
almost  healthy,  but  there  was  a  large  cavity  in  the  right 
lung,  beneath  the  clavicle,  and  an  enormous  effusion  (pyo- 
pneumothorax)  in  the  right  pleura.     Operation^  March  22nd, 


■  The  lower  one  was  valvular,  and  opened  during  inspiration. 

21 


322  SURGERY    OF    THE    CHEST. 

1894  ;  resection  of  sixth,  seventh  and  eighth  ribs,  free 
opening  of  pleura  along  line  of  seventh  rib.  'The  lung  was 
found  adherent  in  front  and  above,  but  at  the  lower  part  of 
the  adhesions  was  an  orifice,  forming  a  communication 
between  the  pleura  and  the  cavity  in  the  lung.  I  shut 
off  the  pleura  from  the  lung  with  four  catgut  sutures, 
cleansed  the  pleura,  and  laid  a  drain  deep  down  in  it.  The 
patient  was  so  weak  that  I  put  off  for  the  present  the  treat- 
ment of  the  cavity.'  He  was  much  improved  by  the 
operation,  and  refused  to  have  anything  done  to  the  lung 
In  June,  he  was  still  doing  well :  the  wound  was  nearly 
healed,  and  he  still  refused  to  let  the  cavity  be  drained.  In 
August,  his  cough  was  worse,  and  the  cavity  again  broke 
into  the  pleura  ;  in  September  he  died. 

Certainly  we  must  admire  the  skill  and  accuracy  of 
these  operations  ;  but  they  still  compel  us  to  ask  whether 
we  may  not  hope,  in  such  cases  as  these,  to  get  equally 
good  results  by  methods  rather  less  severe.  To  suture 
one  perforation  in  a  tubercular  lung  will  not  stop  the 
formation  of  others ;  and  West  has  found  four,  and  even 
six  perforations  in  a  single  case.  The  physical  signs 
before  operation  cannot  give  exactly  the  site  of  the  spot 
where  the  lung  has  given  way ;  it  is  most  likely  to  be 
somewhere  on  the  lateral  aspect  of  the  upper  lobe,  about 
the  level  of  the  third  and  fourth  ribs,  between  the 
anterior  margin  of  the  lung  and  the  axillary  line  ' ;  but 
this  vague  statement  is  not  of  much  practical  value. 
Anyhow,  the  operation  must  be  a  very  serious  proceeding  ; 
it  must  begin  with  a  large  flap  and  with  free  resection  of 
bone.2  And  it  does  not  appear  to  be  absolutely  neces- 
sary to  suture  the  perforation  ;  it  may  heal  spontaneously, 
when  the  effusion  has  been  let  out,  and  the  cavity 
drained. 

*  For  references  on  this  point  see  Marchant's  paper. 

* '  The  resection  of  the  ribs  must  be  very  free  ;  the  amount  of 
chest-wall  sacrificed  must  be  in  proportion  to  the  retraction  of 
the  lung.' 


TUBERCULAR    PHTHISIS.  323 

Again,  there  are  several  recorded  cases  ^  where  success 
has  followed  operations  without  free  exposure  of  the 
lung.  In  1885,  Richardiere  operated  on  a  phthisical 
patient  with  pyo-pneumothorax  of  the  left  side ;  the 
effusion  was  very  large,  the  patient  was  in  a  most  critical 
condition.  Incision  let  out  7  or  8  pints  of  fluid  :  five 
years  later,  the  patient  was  still  alive,  though  the 
wound  had  never  wholly  closed.  In  1891,  Merklen 
published  the  case  of  a  phthisical  patient,  aged  28,  with 
pyo-pneumothorax,  treated  by  punctures  without  any 
good  result.  He  practised  incision,  without  resection, 
and  the  patient  recovered  with  a  fistula,  which  finally 
closed.     Other  similar  instances  might  be  quoted. 

Of  course,  in  fcetid  pyo-pneumothorax,  puncture  is 
useless  :  a  free  incision,  with  perhaps  resection  of  a  piece 
of  rib,  is  the  least  that  can  be  done.  But  I  do  not  think 
that  we  have  at  present  any  clear  evidence  that  it  is 
right  to  do  more  than  this  ;  at  all  events,  one  may  do  this 
first,  not  begin  by  planning  out  a  sort  of  Schede's 
operation  on  a  man  already  stricken  with  phthisis. 

3. — Operation  for  the  Arrest  of  Profuse 
haemoptysis. 

In  1884,  Dr.  Cayley  published  a  case  where,  for 
the  arrest  of  dangerous  haemoptysis  in  tubercular  phthisis, 
he  induced  pneumothorax  and  collapse  of  the  lung  by  an 
incision  through  the  pleura;  and  though  the  patient  soon 
died  of  the  disease,  yet  there  was  reason  to  believe  that 
the  operation  had  succeeded  in  stopping  the  haemor- 
rhage. I  have  not  found  any  record  that  this  method 
has  been  followed  in  England,  but  Heydweiller  alludes 


'  For  references,  see  Galliard,  '  Le  pneumothorax  des  tubercu- 
leux  et  son  traitement,'  "  Medecine  Moderne,"  March  7th,  1894. 


324  SURGERY    OF    THE    CHEST. 

to  it.^  It  was,  of  course,  only  suggested  by  Dr.  Cayley 
as  a  last  resource  ;  and  there  are  insuperable  objections 
to  its  use,  which  found  expression  at  a  meeting  of  the 
Medical  Society,  Dec.  14th,  1885.-     I  put  these  criticisms 

' '  Toussaint,  in  his  account  of  the  surgical  treatment  of  tuber- 
cular disease,  suggests  that  the  occurrence  of  pneumothorax 
in  tubercular  phthisis  has  a  very  good  result  on  the  disease, 
inasmuch  as  it  exercises  pressure  on  the  growing  tubercle,  and 
checks  the  flow  of  blood  to  the  lung.  On  the  strength  of  this 
theory,  some  surgeons  have  set  up  artificial  pneumothorax  in 
cases  of  haemorrhage  from  the  lungs,  by  inflating  the  pleural 
cavity  with  sterilized  air  ;  but  the  patients  died  in  a  few  hours.' 

=  Dr.  Acland  thought  it  would  fail  for  two  reasons  :  i.  If  the 
lung  were  considerably  diseased  and  consolidated,  as  it  often  was, 
then  local  pressure  could  not  be  brought  to  bear  on  the  bleeding 
point ;  2.  If  the  lung  were  not  already  extensively  diseased,  it 
would  be  infiltrated  with  blood  in  a  semi-coagulated  state,  and 
therefore,  again,  local  pressure  could  not  be  applied. 

Dr.  Kingston  Fowler  said  that  Dr.  Cayley  had  only  suggested 
this  treatment  for  such  cases  as  would  otherwise  end  fatally,  and 
his  case  was  of  this  kind.  The  patient,  who  had  for  some  time 
been  suffering  from  profuse  haemoptysis,  shortly  after  the  opera- 
tion brought  up  a  small  quantity  of  blood ;  but  for  some  days 
after  he  brought  up  no  blood.  At  the  fost  mortem,  the  lung  was 
found  collapsed  at  the  site  of  haemorrhage.  He  concluded  that 
the  pressure  which  the  collapse  had  produced  had  contributed 
materially  to  occlude  the  vessel.  In  the  cavity  was  a  laminated 
clot,  and  communicating  with  it  was  a  bronchus  which  evidently 
had  been  occluded  by  the  operation.  He  thought  the  following 
objections  could  be  urged  against  this  operation  :  i.  The  site  of 
advanced  disease  was  usually  also  the  site  of  pleural  adhesion, 
therefore  the  induction  of  pneumothorax  could  not  bring  about 
collapse  of  the  bleeding  tissue ;  2.  Unless  the  air  introduced  were 
aseptic,  it  would  be  likely  to  cause  pleurisy.  Acute  pleurisy  was 
found  in  Dr.  Cayley's  case  ;  and  he  could  not  help  thinking  that 
this  contributed  materially  to  the  fatal  end  of  the  case ;  3.  The  in- 
duction of  pneumothorax  destroys  the  lung  ;  4.  If  the  disease  be 
extensive,  the  surrounding  consolidation  will  prevent  collapse. 
He  thought  therefore  that  it  was  very  rarely  that  the  operation 
could  be  performed ;  and  especial  care  should  be  taken  to  render 
the  introduced  air  aseptic. 

Dr.  West  thought  the  treatment  of  haemoptysis  by  this  method 
was  open  to  considerable  question.  He  had  recently  seen  a  case 
of  phthisis  with  pneumothorax,  in  which  the  air  existed  in  the 
pleural  cavity  at  considerable  pressure,  but  nevertheless  the 
patient  died  of  haemorrhage. 


TUBERCULAR    PHTHISIS.  325 

at  full  length  in  a  note,  as  they  show  clearly  that  the  pro- 
duction of  artificial  pneumothorax,  though  it  may  be 
good  in  theory,  is  not  destined  ever  to  take  a  place 
in  surgical  practice.^ 

Nor  can  anything  be  said  for  the  suggestion  that 
injections  of  some  hsemostatic  substance  into  the  bleeding 
cavity  may  avail  to  stop  the  haemorrhage.  Those  who 
believe  in  the  injection  of  fluids  into  the  lung  say  that 
they  may  be  useful  in  cases  of  haemoptysis,  '  when  the 
site  of  the  haemorrhage  is  limited,  accessible,  and  exactly 
made  out ' ;  but  this  is  what  N^laton  called  '  one  of 
those  indications  for  treatment  that  are  invented  in  the 
library,'  to  which  Dr.  Matthews  Duncan  gave  the  name 
of  '  fireside  pathology.' 

There  remains  a  third  method  of  surgical  treatment 
for  hasmorrhage  from  the  lungs,  and  that  is  the  old  plan 
of  venesection.  In  his  valuable  paper  on  'The 
Treatment  of  Profuse  Haemoptysis  '  ("  Medical  Society's 
Proceedings,"  1886)  Dr.  West  points  out  that  at  least 
this  treatment  is  based  on  sound  principles ;  and  that  the 
cause  of  death  in  these  cases  is  not  so  much  loss  of  blood 
as  suffocation.  But  here  we  are  trespassing  on  purely 
medical  subjects ;  still,  there  seems  reason  to  believe 
that  venesection,  if  we  may  call  it  a  surgical  method,  is 
at  least  more  trustworthy  for  the  arrest  of  profuse  haemo- 
ptysis than  either  the  production  of  pneumothorax  or  the 
use  of  injections  into  the  lung-tissue. 


'  At  the  Medical  Congress  at  Rome  (1894),  ^^-  Forlanini,  of 
Naples,  read  notes  of  some  cases  of  phthisis  which  he  had 
treated  by  making  an  artificial  pneumothorax :  not  to  arrest 
haemorrhage,  but  to  check  the  progress  of  the  disease  itself.  He 
used  oxygen,  making  repeated  injections  of  small  quantities  of  it 
into  the  pleura.  Thg  method  was  very  tedious,  and  its  results 
were  not  very  striking. 


326  SURGERY    OF    THE    CHEST. 

4, — Resection  of  the  Diseased  Portion   of 
THE  Lung. 

Every  surgeon,  when  he  sets  to  work  to  read  some 
small  sub-division  of  the  literature  of  surgery,  is  haunted 
by  the  certainty  that  he  will  find  many  things  that  he 
ought  to  have  done,  and  perhaps  by  the  fear  that  he  will 
find"  some  very  arduous  and  dangerous  operation  that  he 
ought  to  do.  But  he  need  not  be  afraid  that  it  will  ever 
be  his  bounden  duty  to  resect  the  apex  of  the  lung 
for  phthisis.  We  honour  the  names  of  Lowson  and 
Tuffier,  whose  operations  were  successful,  and  those  of 
others  who  deserved  success,  but  did  not  command  it ; 
but  the  indications  for  the  operation  are  so  doubtful,  the 
advantage  of  it  so  uncertain,  and  the  proportion  of  deaths 
from  it  so  large,  that  at  present  there  is  no  clear  reason 
why  the  surgeon  should  undertake  it. 

Here  again,  as  with  intra-pulmonary  injections,  so  with 
removal  of  a  tuberculous  apex,  experiment  gave  hopes 
which  were  not  fully  realized  by  experience.  In  1881, 
Gliick  ligatured  the  whole  root  of  the  lung  in  dogs 
and  rabbits ;  only  two  of  them  died,  the  ligature  having 
interfered  with  the  heart  or  with  the  phrenic  nerve.  He 
then  removed  the  whole  of  the  lung  in  six  dogs  and  fourteen 
rabbits,  making  a  curved  incision  from  the  third  to  the 
sixth  rib,  beginning  one  inch  from  the  edge  of  the 
sternum  ;  sub-periosteal  resection  of  third  to  sixth  ribs, 
free  opening  of  pleura,  lung  drawn  forward,  ligatured  and 
removed ;  careful  cleansing  of  pleura,  wound  closed. 
Very  few  of  the  animals  died  (pericarditis,  purulent 
pleurisy) ;  no  secondary  haemorrhage,  no  thrombosis  of 
the  heart ;  seldom  dyspnoea,  or  any  serious  trouble ; 
rapid  healing,  in  which  the  pedicle  took  active  part.  He 
also  made  numerous  experiments  on  the  dead  body. 

In  the  same  year.  Dr.  Marcus,  of  Jassy,  removed  the 


TUBERCULAR    PHTHISIS.  327 

whole  lung  in  two  dogs  and  three  rabbits.  The  dogs 
died,  one  under  the  ansesthetic,  the  other  of  puru- 
lent pleurisy ;  the  rabbits  died  on  the  third,  sixth  and 
twenty-seventh  days ;  no  troubles  of  the  circulatory 
system  ;  on  several  occasions,  intense  dyspnoea,  stopped 
at  once  by  occlusion  of  the  wound. 

In  1882,  Block  made  numerous  experiments  on  rabbits, 
dogs,  pigs,  and  cows,  some  healthy,  some  tuberculous  ; 
but  these,  most  of  them,  were  not  resections  of  the  whole 
lung.  He  obtained  excellent  results  :  the  pneumothorax 
was  of  short  duration,  and  the  lung  after  the  operation 
expanded  well  and  remained  active. 

In  1 88 1,  Schmidt  made  several  resections  of  part  of 
the  lung,  using  a  temporary  ligature  for  the  arrest  of 
hsemorrhage  during  the  operation.  A  strict  antiseptic 
method  was  not  followed ;  three  of  the  animals  recovered, 
four  died  of  purulent  pleurisy,  one  of  carbolic  acid 
poisoning.     No  secondary  hsemorrhage. 

In  1882,  Biondi  made  numerous  experiments  on  cats, 
dogs,  sheep,  and  other  animals.  His  results  were  very 
good,  as  the  following  table  shows  : — 


Operations.  Recoveries. 
23  12 

34  18 

3  3 


Removal  of  whole  of  the  right  lung 
,,  ,,  ,.       left  lung 

,,  ,1  ).       both  apices 

,,  ,,  ,,       middle  lobe 

,,  ,,  ,,       lower  lobe 

and  he  attributes  the  failure  of  some  of  his  operations 
wholly  to  imperfect  use  of  antiseptics  before,  during,  or 
after  them. 

Unhappily,  the  records  of  surgery  tell  a  different  story ; 
and  it  is  said  that  one  among  those,  whose  names  I  have 
just  mentioned,  died  by  his  own  hand,  being  threatened 
with  a  judicial  enquiry  into  the  case  of  a  patient  who  had 
died  almost  at  once  after  he  had  operated  on  her  for  the 


328  SURGERY    OF    THE    CHEST. 

removal  of  both  apices  for  tubercular  phthisis.  Of  two 
similar  operations  by  Kronlein,  of  Zurich  (1884)  one 
ended  fatally  in  a  few  hours,  the  other  in  a  few  days.  Of 
two  by  Ruggi  1  (1885),  one  patient,  a  feeble,  delicate 
young  man  with  disease  of  the  left  apex,  died  on  the 
ninth  day  from  carbolic  acid  poisoning ;  in  the  other, 
a  man,  aged  30,  with  disease  of  the  right  apex,  it  was 
found  impossible  to  detach  the  lung  from  the  pleura  ;  he 
died  thirty-six  hours  after  the  operation. 

It  is  true  that  at  least  two  operations  have  been 
successful.  In  1893,  Mr.  D.  Lowson^  operated  on  a 
woman,  aged  34,  for  tubercular  disease  of  the  right  apex. 
He  made  an  angular  incision,  beginning  at  the  sternum, 
along  the  second  rib,  and  resected  the  second  and  third 
ribs  ;  then  punctured  the  pleura,  and  slowly  passed  steri- 
lized air  into  it,  to  induce  collapse  of  the  lung.  This 
procedure  caused  no  dyspnoea,  no  cyanosis.  He  then 
opened  the  pleura,  freed  some  adhesions,  and  brought 
the  apex  of  the  lung  out  at  the  wound,  transfixed  it,  and 
put  a  ligature  round  it,  resected  the  diseased  portion,  and 
replaced  the  lung  :  no  subsequent  drainage.  The  part 
removed  was  half  the  size  of  one's  fist,  and  contained 
a  tuberculous  mass  surrounded  by  granulations.  A 
fortnight  after,  there  was  an  accumulation  of  blood,  and 
later  a  purulent  discharge.     She  left  the  Hospital  eighty 


'  He  lays  down  the  following  rules : — The  opening  into  the 
chest  must  be  in  front,  and  must  take  the  whole  space  occupied 
by  the  second,  third,  and  fourth  ribs  from  the  sternum  to  the 
axillary  line.  The  clavicle  must  always  be  avoided ;  the  first  rib 
must,  as  a  rule,  also  be  avoided.  The  skin  incision  may  be  either 
H  or  U-shaped.  The  resection  should  be  made  with  the  cautery, 
not  the  knife ;  and  previous  ligature  or  compression  should  be 
made  of  the  portion  to  be  removed.  Drainage  must  be  used.  It 
is  best  not  to  suture  the  flap  all  round,  for  fear  of  emphysema. 
But  see  TufSer's  operation. 

^"British  Med.  Journal,"  i.  1152,  1893. 


TUBERCULAR    PHTHISIS.  329 

days  after  the  operation,  with  only  a  very  shght  discharge, 
having  gained  rapidly  in  flesh  and  in  appetite.^ 

In  189 1,  M.  Tuffier  operated  on  a  young  man,  aged  19, 
for  tubercular  disease  of  the  right  apex.  He  made  an 
incision  through  the  second  space  down  to  the  pleura  with- 
out opening  it,  and  without  resection  of  rib;  he  then  care- 
fully loosed  the  pleura  off  the  ribs,  as  far  as  he  possibly 
could,  still  without  opening  it,  thus  making  a  sort  of  pneu- 
mothorax outside  it.  Having  felt,  through  the  pleura,  an 
induration  in  the  lung,  he  now  opened  the  pleura,  grasped 
the  lung  with  a  forceps  designed  for  this  purpose,  drew  it 
forward  through  the  slit  in  the  pleura,  and  removed  a  por- 
tion of  it  containing  a  large  tubercular  mass  ;  he  used  no 
subsequent  drainage.  1 2  days  later  he  showed  the  patient, 
healed,  at  the  Societe  de  Chirurgie.  4  years  later  (Oct.  22, 
1 895 )  he  says:  'My  patient  continues  to  enjoy  perfect  health; 
the  breath-sounds  are  absolutely  normal  at  both  apices.'^ 

'  Mr.  Lowson  has  very  kindly  sent  me  a  note  on  this  case.  The 
patient  left  home  to  pay  a  visit ;  she  was  able  to  walk  out,  the  breath 
sounds  were  normal,  the  chest  was  everywhere  clear  on  percussion, 
temperature  normal,  marked  falling-in  of  chest-wall  where  the  ribs 
had  been  resected.  She  came  home  with  signs  of  acute  gastric 
ulcer  (coffee-grounds  vomit,  haemorrhage  from  bowels),  and  died 
about  9  months  after  the  operation.  It  was  impossible  to  get  leave 
iova.post  mortem  examination.  We  must  all  regret  that  the  success 
of  this  most  skilful  operation  was  so  suddenly  brought  to  an  end. 

^'  Surgical  interference  is  easy  enough,  and  free  from  danger, 
in  these  cases,  if  the  surgeon  will  carefully  follow  the  rules  that 
I  have  laid  down.  The  real  risk  is  that  of  pneumothorax  ;  but 
you  can  make  sure  of  avoiding  it,  if  before  you  open  the  pleura 
and  suture  its  two  layers  together,  3'ou  take  care  to  loose  it  off 
the  ribs  all  round  as  far  as  you  can  reach.  In  this  way  you 
establish  a  sort  of  pneumothorax  between  the  chest-wall  and  the 
pleura,  and  this  keeps  the  two  layers  of  the  pleura  in  close 
apposition,  so  that  when  you  do  open  the  pleura  air  does  not 
enter  the  pleural  cavity.  It  may  be  quite  true  to  say  that  tuber- 
cular phthisis,  in  a  general  way,  is  past  the  help  of  surgery  ; 
nevertheless,  there  are  certain  cases  where  the  disease  is  circum- 
scribed, in  which  the  surgeon  may  get  very  good  results.  I  know 
such  cases  are  rare — they  are  the  exception,  not  the  rule — but  still 
they  do  occur. '     The  nodule  was  the  size  of  a  large  hazel-nut. 


330  SURGERY    OF    THE    CHEST. 

To  read  this  operation,  which  was  the  outconie  of 
many  dissections  made  by  M.  Tuffier,  when  he  was  a 
prosector,  for  ascertaining  the  right  way  of  reaching  the 
apex  of  the  lung,  and  to  realize  that  he  cured  his  patient 
by  a  simple  incision,  without  resection,  which  healed 
without  drainage  in  a  few  days,  is  almost  enough  to 
make  one  believe  that  here  is  a  new  field  of  surgery. 
But  the  old  objection  still  holds  good,  that  the  disease  in 
its  early  stage  has  not  come  to  resection,  and  in  its  later 
stages  has  passed  beyond  the  hope  of  benefit  from  it. 

5. — Incision  of  a  Tubercular  Cavity. 

Last  among  the  surgical  measures  possible  for  the 
relief  of  phthisis,  I  have  put  the  one  which,  within  certain 
limits,  has  done  most  good.  Of  course  it  aims  only  at 
alleviation,  not  at  cure ;  but  it  can  perform  what  it 
promises,  and  when  we  know  that  there  are  cases  where 
the  lung,  before  death,  is  simply  one  huge  foetid  thin- 
walled  abscess,  we  are  bound  to  make  the  most  of  the 
only  efficient  method  for  their  relief. 

The  records  of  this  operation  are  not  very  numerous, 
but  the  advantages  that  may  be  gained  from  it  are 
beyond  dispute.  The  earliest  case  is  that  of  one 
Pherseus,  who,  having  a  cavity  in  his  lung,  and  weary  of 
life,  put  himself  in  the  forefront  of  the  battle,  and 
received  a  spear-thrust  which  opened  his  cavity,  and 
restored  his  health.  And,  to  obviate  the  natural  difficulty 
of  believing  this,  there  is  De  Bligny's  case  (1679) :  'The 
son  of  M.  de  la  Genevraye,  a  gentleman  of  high  estate, 
was  the  subject  of  phthisis,  and  all  hope  of  his  recovery 
had  been  abandoned.  In  1670,  he  received  a  wound 
from  a  sword  in  his  chest ;  the  weapon  entered  near  his 
right  breast,  between  the  fourth  and  fifth  ribs,  and  passed 
into   a   cavity  in   his   lung.      There  was   an   abundant 


TUBERCULAR    PHTHISIS.  331 

purulent  evacuation  from  the  wound.      After  this  acci- 
dent, he  completely  recovered  of  his  disease.' 

I  give,  to  begin  with,  a  set  of  cases  to  show  the 
indications  for  this  operation,  and  the  good  that  the 
surgeon  may  hope  will  come  of  it. 

I.'  A  young  man,  aged  19,  of  a  tubercular  family,  after 
many  months  of  treatment  for  'pneumonia'  of  the  right 
lung,  was  admitted  to  Hospital  for  supposed  empyema  of 
right  side  ;  but  careful  examination  showed  signs  rather  of  a 
huge  cavity  in  the  lung.  Operatw?i,  incision  over  sixth  rib, 
a  httle  behind  axillary  line  ;  rib  trephined,"  not  resected  ; 
trochar  and  cannula  thrust  into  cavity,  and  12  ounces  of 
curdy  pus  let  out,  which  was  loaded  with  the  bacilli  of 
tubercle  ;  drainage,  and  daily  irrigation.  Marked  rapid  im- 
provement :  the  temperature  fell  to  normal,  the  cough  and 
expectoration  ceased,  and  the  patient  began  to  put  on  flesh. 
Three  weeks  later  he  broke  down  with  acute  disease  of  the 
opposite  lung,  and  died  a  month  after  the  operation.  Post 
mortem,  the  right  lung,  adherent  over  its  whole  extent,  was 
one  huge  thin-walled  abscess-cavity,  communicating  with  the 
anterior  mediastinum  ;  so  that  this  was  full  of  pus,  and  the 
back  of  the  sternum  was  carious.  The  opposite  lung  was 
everywheie  invaded  with  tubercles,  those  toward  its  centre 
being  most  advanced,  as  though  this  lung  had  become  in- 
fected from  the  other. 

2.  A  man,  aged  38,  was  admitted  to  Hospital  in  January, 
1884,  with  advanced  phthisis.  There  was  diffuse  swelling 
below  the  left  clavicle,  and  finally  a  large  abscess  formed 
here,  the  size  of  one's  fist,  extending  from  the  clavicle  to  the 
fourth  rib  ;  he  suffered  fever,  diarrhoea,  profuse  sweats,  and 
severe  pain.  The  abscess  was  incised,  and  a  large  quantity 
of  very  foetid  sero-purulent  fluid,  with  air  and  sloughs, 
was  let  out  ;  careful  scraping  of  its  walls  exposed  a  channel 
running  inwai'd  through  the  second  space  ;  irrigation  caused 
great  distress  of  breathing.  The  abscess  was  drained  ;  the 
temperature,  which  had  been  over  104^  before  operation, 
never  rose  above  ior3'',  the  discharge  became  less  abundant 
and  less  foetid.     He  died  fifteen  days  after  the  operation. 

'Surgeon-Captain  Moffat,  "Brit.  Med.  Journ. ,"  March  7th, 
1896.     For  other  references,  see  True. 

^Rey  has  lately  revived  this  ancient  method.  See  "Brit. 
Med.  Journ."  Epitome,  Sept.  21st,  1895. 


332  SURGERY    OF    THE    CHEST. 

Post  mortem  examination  showed  extensive  tubercular 
disease  of  both  lungs  ;  very  thick  pleural  adhesions  at  the 
wound,  and  a  channel  running  through  a  thin  laj'er  of  lung- 
tissue  into  an  enormous  cavity  in  the  lung. 

3.  A  man,  aged  31,  was  admitted  to  Hospital  with 
advanced  phthisis  ;  expectoration  purulent  and  foetid,  hectic 
fever,  signs  of  a  large  cavity  in  the  right  apex.  This  was 
punctured  with  a  trochar  and  cannula,  but  only  a  few  drops 
of  pus  escaped,  with  some  air.  The  cavity  was  washed  out 
through  the  cannula,  and  later  the  opening  was  enlarged  ; 
the  toetor  disappeared,  and  the  cough  and  expectoration  were 
diminished,  but  his  general  condition  remained  very  bad. 
He  died  a  month  after  the  operation. 

4.  A  man,  with  advanced  phthisis,  was  admitted  to 
Hospital  with  a  large  cavity  in  the  left  lung.  It  was  incised, 
drained,  and  sprayed  through  the  drainage-tube  ;  it  became 
so  nearly  healed  that  the  tube  had  to  be  first  shortened  and 
then  left  out,  and  neither  pus  nor  air  came  from  the  wound  ; 
the  physical  signs  improved,  the  tenderness  on  percussion 
disappeared,  the  lung  contracted  ;  and  ten  weeks  after  the 
operation  he  had  so  far  gained  strength  and  weight  that  he 
left  the  Hospital  and  went  back  to  work.  Eight  months 
later,  he  returned  with  fresh  extension  of  the  disease,  both 
lungs  being  now  affected,  and  died  a  year  and  a  quarter 
after  the  operation.  Post  mortem  examination  showed  wide- 
spread tuberculosis  and  amyloid  disease. 

5.^  A  man,  aged  38,  with  a  history  of  hsemoptysis  in  1841 
and  1843,  was  in  1844  suffering  painful  cough  with  profuse 
purulent  blood-stained  expectoration,  and  showed  signs  of  a 
cavity  below  the  left  clavicle,  with  some  dulness  and 
bronchial  breathing  over  the  opposite  lung.  An  incision  was 
made  over  the  cavity,  and  it  was  punctured  with  a  trochar 
and  cannula  ;  only  air  escaped,  and  there  was  a  little  bleed- 
ing from  the  wound  and  from  the  mouth.  A  tube  was 
inserted,  but  did  not  fit,  and  was  taken  out,  the  wound  being 
simply  covered  with  a  water  dressing ;  two  days  later,  a 
piece  of  catheter  was  inserted.  His  cough  and  expectoration 
almost  disappeared,  and  pus  flowed  from  the  cavity  on 
the  ninth  day  after  operation.  Three  weeks  later,  the  cavity 
was  nearly  closed,  and  his  general  health  and  strength  were 
greatly  improved. 

I  believe  that  these  five  cases  show  fairly  the  measure 

^  This  is  the  famous  Hastings-Storks  case. 


TUBERCULAR    PHTHISIS.  333 

of  good  that  the  surgeon  may  hope  to  do  by  incision  and 

drainage  of  a  tubercular  cavity.      He  may,  of  course, 

meet  with  difficulties  :    in   one   case,    a    circumscribed 

pneumothorax  in  a  phthisical  patient  was  incised  in  the 

belief  that  it  was  a  cavity  in  the  lung  ;  in  another,  the 

surgeon  made  his  incision  too  low,  indeed  between  the 

eleventh   and  twelfth  ribs,  and  failed  to  drain  a  huge 

cavity;    in  another,  there  was  troublesome  haemorrhage 

from  the  cavity  after  operation ;  in  more  than  one,  the 

use  of  irrigation  gave  considerable  distress.     Nor  can  he 

ever  expect  to  cure  his  patient;   and   out  of  13  cases 

collected  by  True,   6  died  within  three  months  of  the 

operation.!     Still,  in  some  cases,  he  may  give  great  relief 

for  a  time,  and  may  be  able  to  ensure  that  his  patient 

shall  at  least  be  saved  from  acute  distress  during  the 

short  span  of  life  that  is  all  he  can  hope  to  have.     And 

we  must  note  that  Sonnenburg  (1891)  got  very  good 

results,  in  two  cases,  from  the  use  of  Koch's  fluid  after 

the    operation.      He   speaks   very  emphatically  of  the 

value   of    this    method,    observing  that    we   can   thus, 

when  the  cavity  has  been  opened  and  drained,  bring 

about  a  healthy  change  in  its  walls  without  risk  to  the 

patient. 

The    four    following    cases  ^    illustrate    three    of   the 

troubles  that  I  have  just  mentioned  :    mistake  of  the 

pneumothorax  for  the  tubercular  cavity,  haemorrhage  after 

the  operation,  and  failure  to  find  the  cavity. 

I.  A  man,  aged  29,  in  advanced  phthisis,  with  violent 
cough,  purulent  expectoration,  fever,  and  emaciation,  pre- 
sented signs  of  a  large  superficial  cavity  in  the  upper  part  of 
the  left  lung  (fulness  over  first  and  second  spaces,  bronchial 
breathing  and  cracked-pot  sound  below  left  clavicle,  dulness 

'  Poisier  and  Jonnesco  ("  Gaz.  des  Hop. ,"  1891)  collected  29 
cases  :  10  deaths,  15  improvements,  4  '  recoveries.' 
"  Bull,  1883  ;  Delorme,  1889 ;  Michaux,  1890  and  1893. 


334  SURGERY    OF    THE    CHEST. 

above  both  clavicles,  moist  rales  both  sides,  most  marked 
over  left  apex)  and  the  diagnosis  was  made  that  he  had 
a  superficial  cavity,  with  pleural  adhesions.  Exploratory 
puncture  only  drew  blood  and  caused  the  sputa  to  be  blood- 
stained. An  incision  was  made,  and  an  empty,  circumscribed 
cavity  was  exposed ;  at  the  bottom  of  it  lay  lung  tissue, 
as  was  proved  by  puncture  with  a  director.  Nothing  more 
was  done.  Next  day  some  pus  flowed  from  the  wound,  four 
days  later  it  became  foetid,  and  next  day  the  patient  died. 
Pos^  mortem.,  the  incision  had  opened  a  circumscribed 
pneumothorax  ;  the  lung  was  retracted  two  inches  from  the 
chest-wall ;  there  was  a  large  cavity  in  it,  about  an  inch 
above  the  level  of  the  operation-wound,  unopened. 

2.  A  young  man,  with  pyo-pneumothorax,  was  treated 
with  incision  (1889)  in  the  usual  way;  irrigation  was  at- 
tempted at  the  time  of  the  operation,  but  caused  convulsive 
cough  and  some  haemoptysis.  Two  hours  later,  he  had  a 
sudden  profuse  haemoptysis,  and  the  dressings  and  the  bed 
were  soaked  with  blood.  'What  was  I  to  do?  It  was  no 
good  trying  compression,  or  occlusion  of  the  wound,  or 
fixation  of  the  chest  with  a  bandage.  I  removed  the  dressing, 
and  found  blood  flowing  in  jets  through  the  drainage-tubes. 
First,  I  plugged  the  wound,  but  without  hoping  to  do  much 
good  in  this  way  ;  then,  as  the  patient  was  still  getting 
weaker,  I  took  out  the  plug,  opened  up  the  wound,  injected 
iced  water  into  the  pleura,  slipped  pieces  of  ice  into  the 
chest,  put  ice  outside  it,  and  compressed  the  main  arteries  of 
the  limbs.  As  this  was  not  enough,  and  he  was  terribly 
blanched,  I  had  recourse  to  digitalin  and  to  ergotin,  keeping 
on  with  the  ice.  The  bleeding  stopped  at  last,  more  from 
syncope  than  from  treatment  ;  but  the  fear  of  bringing  it  on 
again  made  the  work  of  restoring  him  very  anxious,  and  I 
did  not  leave  his  side  for  seven  hours.' 

3.  A  woman,  aged  26,  was  admitted  to  Hospital,  having 
taken  poison  to  be  rid  of  her  sufferings  :  these  had  begun  six 
years  ago,  with  pleurisy,  and  for  four  years  she  had  suffered 
profuse  purulent  expectoration,  sometimes  foetid.  In  spite 
of  repeated  careful  examinations,  exact  diagnosis  was  im- 
possible ;  it  lay  between  a  cavity  due  to  bronchiectasis,  with 
chronic  pneumonia,  and  an  empyema  toward  the  diaphragm 
with  an  opening  into  the  lung  ;  and  she  remained  for  over  a 
year  in  Hospital  before  operation.  Then  an  incision  was 
made,  and  four  inches  each  of  the  seventh  and  eighth  ribs 
were  resected  ;  the  pleura  was  opened,  and  it  was  noted  that 
the  lung  was  slightly  oedematous,  congested,  and  firm,  but  no 


TUBERCULAR    PHTHISIS.  335 

defined  induration  was  felt.  A  fine  aspirating  needle  was 
passed  in  eight  or  ten  different  directions  into  the  lower  lobe 
of  the  lung  without  finding  either  the  slightest  trace  of  a 
cavity  or  the  very  smallest  patch  of  indurated  tissue. 
Finally,  with  Paquelin's  cautery,  an  incision  was  made 
through  the  lung,  three  or  four  inches  long,  and  at  least  two 
inches  deep  ;  some  dilated  bronchi  were  thus  opened  up, 
but  no  pus  and  no  cavity  were  anywhere  to  be  found  ; 
the  wound  was  left  open,  and  packed  with  iodoform  gauze. 
No  marked  improvement  followed,  and  she  died  about  a 
month  later.  Post  inortei)i^  there  was  found  a  very  small 
cavity,  deep  in  the  lung,  not  far  from  the  track  of  the  cautery, 
in  the  thickness  of  the  inner  part  of  the  lower  lobe,  with 
tubercular  phthisis. 

4.  A  woman,  aged  28,  was  admitted  to  Hospital  for  oper- 
ation, having  either  a  small  tubercular  cavity  or  a  bronchial 
dilatation  at  the  base  of  one  lung.  As  the  physical  signs 
were  not  sharply  defined,  operation  was  put  off,  and  she  left 
the  Hospital,  but  returned  in  a  few  days.  The  probable 
site  of  the  cavity  was  now  very  carefully  mapped  out  on  the 
chest-wall,  an  H-shaped  incision  was  made  below  the  angle 
of  the  scapula,  and  about  two  inches  each  of  the  eighth  and 
ninth  ribs  were  resected.  With  a  Paquelin's  cautery,  an  in- 
cision was  made  in  the  lung,  about  two  inches  long,  and 
about  two  inches  deep  ;  but  no  cavity  was  anywhere  found. 
She  died  about  three  months  later,  with  signs  of  bronchiec- 
tasis and  tubercular  phthisis.  Post  mortem,  the  tubercular 
changes  were  most  marked. 


We  have  now  reviewed  the  five  methods  of  surgery 
which  have  at  present  been  found  possible  for  the  treat- 
ment of  tubercular  phthisis ;  and  we  have  found  that 
the  two  sets  of  cases  where  the  surgeon  may  do  most 
good  are  those  of  foetid  pyo-pneumothorax,  and  those  of 
large  tubercular  cavity  with  septic  absorption.  It  is  the 
general  condition  of  the  patient  that  gives  the  key  to  the 
question  of  interference  or  non-interference  ;  and  such 
relief  may  be  given  by  incision  and  drainage  that  the 
operation  may  most  truly  be  successful,  even  though  the 
disease  goes  on  to  its  natural  end. 


336 


CHAPTER  XXII. 

SOME  DISEASES  OF  THE  BRONCHIAL  GLANDS  AND 
POSTERIOR   MEDIASTINUM. 

We  have  now  come  to  a  group  of  diseases  that  oppose  to 
the  physician  and  to  the  surgeon  almost  insuperable 
difficulties.  The  various  forms  of  inflammation  of  the 
bronchial  and  mediastinal  glands,  though  they  frequently 
end  in  death,  are  often  unrecognized  during  life.  They 
tax  to  the  utmost  the  physician's  powers  of  diagnosis, 
and  are  almost  out  of  the  surgeon's  reach.  Not  that 
it  is  impossible,  by  a  carefully  planned  operation,  to 
gain  access  to  the  posterior  mediastinum ;  but,  by 
the  time  the  indications  for  such  interference  are  clearly 
marked,  the  harm  has  already  been  done  :  and,  at 
present,  in  spite  of  the  anatomical  work  of  Quenu  and 
Hartmann,  Nosiloff,  and  Joseph  Bryant,  we  can  hardly 
speak  of  the  surgery  of  the  posterior  mediastinum. 
Still,  there  is  no  anatomical  reason  against  it ;  and, 
apart  from  the  possibility  that  we  may  come  to  operate 
directly  and  of  set  purpose  on  this  region  of  the  body, 
the  diseases  of  these  glands,  and  of  the  mediastinal  space 
that  contains  them,  may  in  this  or  that  case  stand  in 
need  of  surgery  :  we  are  therefore  bound  to  make  care- 
ful study  of  them.  It  is  only  of  late  years  that  much 
has  been  written  about  them  :  what  I  put  here  is  mostly 
taken  from  the  work  of  Neveux,  Beez,  Seitz,  Kolisko,  and 
Voelcker. 

The  bronchial  and  mediastinal  glands  are  so  numerous, 
and  set  so  close  together,  that  it  seems  hardly  reasonable 


Plate  x. 


The  Bronchial  and  Mediastinal  Glands,  seen  from  behind.     (From  Gueneau 
de  Mussy,  Clinique  Me'dicale,  vol.  iv.) 


\Face  p   337- 


DISEASES    OF   BRONCHIAL    GLANDS,    ETC.      337 

to  describe  separate  groups  of  them,  but  they  are  chiefly 
to  be  noted  :  (i)  in  front  of  the  bifurcation  of  the 
trachea,  and  in  close  connection  with  the  main  bronchi ; 

(2)  beneath    the    bifurcation    and    the    main    bronchi ; 

(3)  in  the  angles  of  the  chief  branches  of  the  bronchi ; 

(4)  round  the  oesophagus.  The  illustration  {Plate  X.) 
shows  clearly  that  they  are  only  too  likely  either  to  catch 
infection  or  spread  it,  and  are  indeed  dangerous  neigh- 
bours, easily  provoked  and  hard  to  withstand. 

Setting  aside  malignant  disease,'  there  are  three  infec- 
tive diseases  of  these  glands  we  have  to  consider.  First, 
acute  septic  inflammation  with  sloughing  ;  next,  chronic 
inflammation,  with  pigmentation  and  fibrous  and  cal- 
careous degeneration  ;  last,  tuberculous  disease.  It  is,  of 
course,  possible  for  a  mixed  infection  to  occur :  still, 
these  three  forms  are  so  far  distinct  that  we  must,  for 
practical  purposes,  consider  them  separately. 

Acute  Septic  or  Gangrenous  Inflammation. 

We  owe  to  Neveux-  our  gratitude  for  an  admirable 
account  of  this  disease.  He  has  described  it  so  clearly 
and  fully,  that  we  come  in  danger  of  forgetting  that  its 
diagnosis  is  full  of  difficulty,  and  that  there  is  at  present 
no  record  of  an  operation  practised  directly  for  its  relief. 
The  following  abstract  of  his  work  may  at  least  serve  to 
show  its  great  value  : — 

'During  the  last  twenty  years,'  he  says,  'we  have  begun 
to  study  the  diseases,  acute  and  chronic,  of  these  glands; 
we  look  for  them  in  every  post  morte??i  examination  ;  we 
diagnose  some  of  them  at  the  bedside.    It  is  certain  that 

'  For  primary  malignant  disease  of  these  glands,  see  a  paper 
by  Dr.  Newton  Pitt,  "  Path.  Soc,  Trans.,"  1888,  p.  54. 

^  Georges  Neveux  "  De  la  Gangrene  du  Mediastin,  et  de  la 
Gangrene  Pulmonaire  Consecutive,"  Paris,  1895. 

22 


338  SURGERY    OF    THE    CHEST. 

one  day  we  shall  diagnose  them  all :  and  we  must  hope 
that  surgery,  always  making  fresh  claims  and  always  justi- 
fying them,  will  in  time  find  a  way  into  the  posterior 
mediastinum,  and  reach  the  sloughing  glands  in  it,  just 
as  the  surgeons  of  the  present  day  open  a  gangrenous 
cavity  in  the  lung.'  Gangrene  of  the  mediastinum  has 
at  present  been  overlooked,  or  confounded  with  gangrene 
of  the  lung,  which  is  a  common  result  of  it,  and  vice  versa 
may  be  the  cause  of  it.  But  in  nine  cases  out  of  ten  the 
cause  is  ulceration  and  perforation  of  the  oesophagus. 

Barety  was  one  of  the  first  to  call  attention  to  it.  He 
put  together  four  cases  of  gangrenous  inflammation  of 
the  glands,  one  from  gangrene  of  the  larynx,  one  from 
septic  endocarditis,  one  from  gangrene  of  the  lung,  and 
one  where  the  glands  themselves  seemed  to  be  primarily 
attacked.  Gangrene  of  the  mediastinum,  then,  is  not 
always  due  to  perforation  of  the  oesophagus  :  and  again, 
it  may  come  from  extension  of  inflammation  downward 
from  the  neck  (cellulitis,  retro-pharyngeal  abscess)  or 
from  extension  of  disease  from  the  lung.  Again,  the 
perforation  of  the  oesophagus,  which  is  the  one  great 
cause  of  the  disease,  may  of  itself  be  due  to  degeneration 
(tuberculous,  calcareous,  or  syphilitic)  of  the  very  glands 
which  now  in  their  turn  become  infected  from  the 
cesophagus.  Still,  the  rule  holds  good  that  gangrene  of 
the  mediastinum  is  due,  in  almost  every  case,  to  putrid 
infection  of  the  mediastinal  glands  from  ulceration  of  the 
oesophagus.  The  causes  of  this  ulceration  are  of  all 
sorts  and  kinds  :  laceration  by  foreign  bodies,  by  sword- 
^wallowing,  by  rough  use  of  a  bougie,  burns  with  corro- 
sive fluids,  stricture,  malignant  disease,  and  various 
forms  of  inflammation  in  or  immediately  around  the 
oesophagus. 

The   abscess- cavity   caused   by  the   sloughing  of  the 


DISEASES    OF    BRONCHIAL    GLANDS,    ETC.      339 

glands  thus  infected  is  usually  situated  at  the  bifur- 
cation of  the  trachea,  behind  and  below  the  right 
bronchus  :  in  front  of  it  is  the  pericardium  ;  behind  it, 
the  adherent  pleura  ;  above,  the  right  bronchus  and  the 
root  of  the  lung  ;  to  its  right  side,  the  right  lung  ;  to  its 
left,  the  oesophagus,  the  right  pneumogastric  nerve,  and 
the  arch  of  the  aorta.  It  is  rarely  more  than  an  inch  or 
so  in  diameter,  in  one  case  only  it  measured  2|-  inches. 
Its  walls  are  soft,  dark,  smooth,  and  regular,  not  sinuous 
like  the  walls  of  a  gangrenous  cavity  in  the  lung;  its 
contents  are  greyish,  foetid,  and  may  contain  the  rem- 
nants of  a  gland,  or  what  remains  of  the  gland  may  be 
found  still  adherent  to  the  walls  of  the  cavity. 

Perforation  may  occur  in  many  ways.  There  may  be 
purulent  or  gangrenous  pleurisy,  or  foetid  pyo-pneumo- 
thorax,  from  a  large  irregular  ragged  perforation  into  the 
pleura,  far  back,  near  the  posterior  border  of  the  lung. 
There  may  be  putrid  bronchitis,  or  broncho-pneumonia, 
from  a  perforation  of  the  right  bronchus,  or  of  the  left, 
or  of  both — small,  clean-cut  openings,  as  if  they  had  been 
punched  out.  The  lung  may  be  perforated,  and  become 
the  seat  of  gangrene,  diffuse  rather  than  circumscribed: 
or  the  foetid  pleural  effusion  due  to  perforation  of  the 
pleura,  may  set  up  a  superficial  gangrene  of  the  lung. 
The  great  vessels  may  give  way,  though  this  very  rarely 
happens ;  or  the  oesophagus  itself,  the  cause  of  the 
disease,  may  in  its  turn  be  perforated  by  it. 

The  organisms  that  bring  about  these  evil  results  are 
the  same  that  are  found  in  gangrene  of  the  lung,  and  in 
putrid  empyema  ;  not  only  the  streptococci  and  staphy- 
lococci, but  higher  forms  of  life,  spirilla  and  amoeb^.^ 

The  symptoms  of  mediastinal  gangrene  are  so  nearly 

'  It  has  been  shown  that  the  injection  of  saliva  into  the  lungs 
of  a  rabbit  is  invariably  followed  by  pulmonary  gangrene. 


340  SURGERY    OF    THE    CHEST. 

those  of  gangrene  of  the  lung,  that  an  exact  diagnosis  is 
ahnost  impossible.  But  a  clear  history  of  some  previous 
injury  or  disease  of  the  oesophagus  may  help  toward  it, 
and  the  patient  may  complain,  early  in  the  disease,  of 
sharp  pain  behind  the  sternum,  or  down  along  the  spine. 
Except  for  these  vague  indications,  the  other  signs  of 
the  attack — a  general  feeling  of  illness,  distaste  for  food, 
cough,  fever,  shiverings — give  no  definite  information  ; 
but  it  is  to  be  noted  that  the  breath  may  be  foetid  very 
early  in  the  disease.  Later,  the  signs  are  those  of  the 
extension  of  the  gangrenous  process,  by  infiltration  or 
perforation,  beyond  its  original  site — the  case  becomes 
one  of  diffuse  or  (more  rarely)  circumscribed  gangrene 
of  the  lung,  or  putrid  empyema,  or  pyo-pneumothorax, 
and  is  treated  as  such,  without  success. 

This  abstract  of  Neveux's  account  of  mediastinal  gan- 
grene must  not  make  us  forget  that  it  can  hardly,  during 
life,  be  distinguished  from  gangrene  of  the  lung,  and 
that  up  to  the  present  time  there  is  no  record  of  any 
direct  operation  on  it.  It  belongs  at  present  to  pathology 
rather  than  to  clinical  medicine  or  surgery.  '  We  must 
hope,'  he  says,  '  that  more  cases  will  be  published,  that 
it  will  take  its  place  among  recognized  diseases,  and  that 
we  shall  finally  be  able  to  diagnose  it.  When  this  has 
been  done,  the  surgeon  who  operates  on  the  gangrene  of 
the  lung  that  is  the  result  of  it,  will  also  operate  on  the 
disease  at  its  starting-point,  and  from  this  rational  treat- 
ment we  may  expect  definite  good  results.' 

Chronic  Inflammation  and  Degeneration. 

The  bronchial  and  mediastinal  glands  of  all  those  who 
hve  in  cities,  or  work  at  dusty  trades — stone-masons, 
felt  -  workers,  pitmen  —  tend  to  become  pigmented, 
shrunken,  tough,  and  degenerate;  fibrous  toward  their 


DISEASES    OF   BRONCHIAL    GLANDS,   ETC.      341 

surfaces,  broken-down  or  calcareous  toward  their  centres. 
These  changes  come  so  slowly  that  they  belong  essen- 
tially to  adult  or  late  life,  and  have  only  once  or  twice 
been  noted  in  children.  They  seldom  do  harm,  but 
in  a  few  cases  the  gradual  shrinking  of  the  glands  and 
their  adhesions  has  caused  narrowing  or  kinking  of  the 
oesophagus,  the  air-passages,  or  the  great  vessels ;  or 
even  perforation  has  occurred  :  or,  after  lying  harmless 
for  years,  the  glands  may  become  the  seat  of  some  fresh 
infection  leading  to  acute  or  gangrenous  suppuration. 

To  illustrate  compression  and  perforation  of  the  air- 
passages,  we  may  take  the  account  of  two  specimens 
given  by  Tiedemann.^ 

1.  '  The  whole  trachea,  at  its  bifurcation,  is  so  narrowed 
that  the  passage  is  reduced  to  a  mere  slit.  It  is  surrounded 
here  by  a  thick,  fibrous  growth,  an  inch  thick  in  some  places, 
which  has  pushed  the  cartilaginous  rings  inward  ;  this  is 
composed  of  very  dense,  fasciculated  fibrous  tissue — part 
greyish-white,  part  pigmented — enclosing  shrunken,  broken- 
down,  crumbly  glands.  The  right  bronchus  is  also  con- 
stricted by  the  growth.' 

2.  '  In  the  left  bronchus,  the  third  and  fourth  rings  touch, 
and  project  inward  into  the  bronchus,  and  between  them  is  a 
pin-head  opening  leading  into  a  minute  diverticulum.  The 
fifth  ring  is  broken,  and  the  mucous  membrane  over  it  is 
sunken.  Round  the  bronchus  is  a  quantity  of  whitish  fascicu- 
lated scar-tissue,  containing,  just  at  the  point  where  the 
bronchus  is  diseased,  the  remains  of  a  shrunken,  pigmented, 
calcareous  gland.' 

Or  the  glands  and  the  tissue  round  them  may,  as  they 
shrink,  drag  on  the  oesophagus  and  cause  pouching  of 
its  wall.  These  '  traction-diverticula '  of  the  oesophagus 
have  been  studied  by  Zenker,  who  collected  60  instances. 

'  For  this  and  other  references,  and  a  good  account  of  the 
whole  subject,  see  Beez,  "  Ueber  Seltenere  Vorkommnisse  bei 
Necrose  und  Vereiterung  von  Bronchial-driisen,"  Inaug.  Diss., 
Jena,  1895.  Also  a  paper  by  Dr.  Rolleston,  "Path.  Soc.  Trans." 
1894,  p.  23. 


342  SURGERY    OF    THE    CHEST. 

They  occur,  of  course,  about  the  level  of  the  bifurcation 
of  the  trachea,  and  are  usually  directed  upward  :  in  most 
of  them,  the  muscular  fibres  are  frayed  out,  and  the 
mucous  membrane  is  wrinkled  and  pigmented.  They 
are  so  small  (being  on  an  average  the  size  of  a  pea)  that 
their  importance  comes  only  from  the  danger  of  per- 
foration. 

Biedert  gives  a  long  list  of  the  effects  that  may  follow 
various  diseases  of  the  bronchial  glands.  He  collected 
in  all  420  cases  :  in  8,  the  aorta  was  compressed ;  in  22, 
the  pulmonary  artery ;  in  6,  the  vena  cava  superior ;  in 
I,  both  the  pulmonary  artery  and  the  veins  ;  and  in  i, 
the  vena  azygos.  The  trachea  and  the  bronchi  were 
compressed  in  77,  perforated  in  57,  and  were  the  seat  of 
diverticula  in  4.  The  oesophagus  was  compressed  in  8, 
perforated  in  18,  and  was  the  seat  of  diverticula  in  50. 
The  most  likely  sites  for  perforation  of  the  trachea  or 
bronchi  are  the  angles  of  bifurcation,  these  being 
naturally  beset  with  glands.  Pressure  may  also  fall  on 
the  pneumogastric  and  recurrent  laryngeal  nerves,  very 
rarely  on  the  phrenic. 

The  following  two  cases  ^  are  good  examples  of  this 
chronic  degeneration  of  the  glands  in  adult  life,  ending 
in  a  fatal  re-infection.  It  will  be  noted  that  these  old, 
shrunken,  or  calcified  glands  may  have  been  in  early  life 
tuberculous. 

I.  A  woman,  aged  64,  was  admitted  to  Hospital  already 
dying  :  all  that  could  be  learned  of  her  was  that  she  was  in 
her  usual  health  up  to  ten  weeks  ago,  when  she  began  to 
cough,  and  frequently  complained  of  cuttmg  pains  in  the 
chest.     Post  mortem  examination  showed  general  parenchy- 

^  Kolisko,  "  Alter  Abscess  der  Bronchialdriisen,  durch  Perfo- 
ration zur  Mediastinalen  Phlegmone  fiihrend,"  "Wien.  Klin. 
Wchnschr.,"  1891,  p.  665.  Tice,  "  Med.  Chir.  Soc.  Trans."  1S43, 
p.  19. 


DISEASES    OF   BRONCHIAL    GLANDS.    ETC.      343 

matous  degeneration  of  the  viscera,  and  acute  swelling  of 
the  spleen,  pointing  to  some  acute  recent  infection.  All 
the  loose  cellular  tissue  of  the  posterior  mediastinum  was 
infiltrated  with  sero-purulenl  fluid,  especially  above  the 
bifurcation  of  the  trachea.  Lower  down,  between  the  main 
bronchi,  was  a  large,  thick-walled  abscess  cavity,  containing 
similar  fluid:  it  pushed  the  bronchi  outward  and  partly 
occluded  them,  and  pushed  the  oesophagus  Ixackward  and  to 
the  left  ;  and  it  opened,  below  the  right  bronchus,  into  the 
posterior  mediastinum.  In  its  wall  lay  a  small  pigmented, 
degenerate,  partly-calcified  lymph-gland,  which  also  had 
perforated  the  right  bronchus  :  and  this  bronchus  was  ulcer- 
ated higher  up  over  another  similar  gland.  The  whole 
process  had  evidently  taken  a  long  time  :  the  glands  may 
have  been  originally  tuberculous  :  the  abscess-cavity  had 
been  there  probably  for  many  years,  and  then  some  fresb 
infection  had  made  it  enlarge  and  break  into  the  posterior 
mediastinum.  The  perforation  of  the  bronchus,  from  its 
thin  and  scarred  edges,  was  of  long  standing. 

2.  A  man,  aged  48,  began  about  September  7th,  1 842,  to 
complain  of  pain  in  the  right  side,  slight  embarrassment  of 
breathing,  and  a  very  foul  taste  in  his  mouth  of  a  morning, 
and  pressure  over  the  liver  gave  him  pain  :  he  was  treated 
with  purgatives  and  venesection,  and  got  worse.  A  few  days, 
later,  he  began  to  have  paroxysms  of  coughing,  and  was. 
easiest  when  he  was  leaning  forward  with  his  hands  on  his. 
knees.  He  was  distressed  at  the  fcetor  of  his  own  breath,  but 
this  was  not  perceptible  to  others.  He  still  referred  his  pain, 
to  the  liver,  and  had  sharp  pain  when  it  was  pressed  upward 
against  the  diaphragm.  He  got  steadily  worse,  and  many 
kinds  of  diagnosis  and  of  treatment  were  given  and  then 
abandoned.  He  now  stated  that  he  had  felt  pain  in  his 
chest  while  eating  a  pear  three  weeks  before  his  illness,  and 
thought  some  of  it  must  have  stuck  on  the  way  down  ;  and 
he  pointed  to  a  place  a  little  below  the  left  clavicle,  where 
everything  that  he  swallowed  still  seemed  to  stick.  In 
October  he  was  worse  in  every  way,  with  profuse  foetid- 
expectoration,  and  attacks  of  faintness  and  of  choking. 
The  lungs  became  congested,  and  he  died  comatose  on 
October  i8th,  after  six  weeks'  illness.  The  posf  mortem 
examination  showed  a  foetid  abscess-cavity  in  a  mass  of 
glands  at  the  bifurcation  of  the  trachea,  opening  wide  into. 
loth  bronchi,  and  into  the  oesophagus.  It  contained  a 
quantity  of  calcareous  matter,  and  a  hard  calcareous  mass 
was  wedged  in  the  opening  into  the  right  bronchus. 


344  SURGERY    OF    THE    CHEST. 

The  second  of  these  two  cases  is,  I  beheve,  the  earHest 
record  of  this  form  of  mediastinal  abscess  ;  and  Dr. 
Tice's  account  of  it  gives  a  most  admirable  picture  of 
the  disease. 

Tuberculous  Abscess  of  Children. 

We  come  now  to  a  set  of  cases  that  are  somewhat 
more  definite  in  character,  and  have  been  of  late  years 
very  carefully  studied.  The  work  of  Voelcker,  Pitts, 
Seitz,!  and  many  others,  has  given  us  a  clear  picture  of 
the  disease :  and  early  recognition  of  it  may  help  us  to 
check  its  progress.  The  fact  that  it  may  be  excited  by 
any  long-contmued  irritation  of  the  glands  must  make  us 
careful  to  treat  cases  of  simple  chronic  cough  in  children. 

These  cases  of  tuberculous  bronchial  and  mediastinal 
glands  in  childhood  seem  to  divide  themselves  into  two 
chief  groups,  which  we  may  practically  call  early  and  late, 
or  medical  and  surgical,  or  before  perforation  and  after  it. 
This  division,  though  it  looks  absurd,  is  justified  by  the 
•changes  which  follow  perforation,  calling  in  most  cases 
for  such  relief  as  an  operation  may  be  able  to  give.  To 
illustrate  the  diagnosis  of  the  disease  in  its  earlier  stages, 
I  give  a  case  from  Dr.  Voelcker's  work  on  this  sul)ject, 
and  an  abstract  of  Seitz's  paper  and  of  the  discussion 
that  followed  it :  but  Seitz's  list  of  signs  and  symptoms 
is  derived  from  other  diseases  of  these  glands  as  well  as 
from  that  which  we  are  now  considering,  and  seems  to 

^  Voelcker,  "  On  some  Effects  produced  by  Caseous  Bronchial 
'Glands  in  Children,"  "Practitioner,"  June,  1895;  Pitts,  "Surgery 
of  the  Air-passages  and  Thorax  in  Children,"  "  Lancet,"  Oct.  1893; 
Seitz,  "Die  Klinische  Diagnose  der  Bronchialdriisen-erkran- 
kungen,"  "Wien.  Klin.  Wchnschr.,"  1894,  p.  968.  Thecaseshere 
quoted  are  taken  from  Voelcker  and  Pitts.  See  also  Gee,  "St. 
Bart.  Hospl.  Reports,"  1877,  p.  63:  and  Gulliver,  "Path.  Soc. 
Trans.,"  1889,  p.  38. 


DISEASES    OF   BRONCHIAL    GLANDS,    ETC.      345 

include   not  only  what  we  do   find   in  these  cases,  but 
also  all  that  we  might  find. 

A  little  boy,  6  years  old,  was  admitted  to  Hospital  with 
cough,  shortness  of  breath,  night-sweats,  wasting,  and  vomit- 
ing ;  no  haemoptysis.  (It  was  said  that  he  had  swallowed  a 
small  lead  weight,  about  three  months  before  admission,  and 
had  never  since  then  seemed  well.)  There  was  deficient 
movement  of  the  right  side  of  the  chest  ;  the  breath-sounds 
were  weaker  over  the  right  side  than  over  the  left ;  a  few 
moist  rales  were  heard,  during  inspiration,  on  the  right  side 
only.  Two  days  later,  there  was  faint  but  distinct  tubular 
breathing  over  the  right  interscapular  space,  at  the  level  of 
the  spine  of  the  scapula,  and  the  voice-sounds  here  had 
a  nasal  tone.  Five  days  later,  the  breath-sounds  were 
markedly  weaker  over  the  right  upper  lobe  than  over  the 
left,  and  vocal  fremitus  and  vocal  resonance  were  more 
marked  in  the  right  interscapular  region  than  in  the  left. 
From  this  time  onward,  the  signs  were  those  of  rapid 
phthisis  of  both  lungs  ;  but  repeated  examinations  failed  to 
find  the  tubercle-bacillus.  He  died  six  weeks  after  admis- 
sion :  the  pos^  mortem  examination  showed  a  large  mass  of 
caseous  glands  at  the  bifurcation  of  the  trachea,  measuring 
\\  by  2  inches,  flattening  the  right  bronchus  :  advanced 
tubercular  disease  of  both  lungs. 

Seitz,  in  an  elaborate  paper  on  the  diagnosis  ot  diseases 
of  the  bronchial  glands,  takes  first  their  effects  on  the 
structures  in  their  neighbourhood,  and  then  the  physical 
signs  that  they  may  present.  Under  the  first  division 
(functional  disturbances)  he  puts  the  following  changes : — 

1.  Compression  of  trachea  or  bronchi,  leading  to 
inspiratory  dyspncea,  which  is  intermittent,  and  becomes 
worse  when  the  patient  sits  up  :  very  suggestive  if  it  be 
more  marked  on  one  side  than  on  the  other  ;  later,  there 
may  be  signs  of  bronchiectasis. 

2.  Dilatation  of  the  veins  of  the  face,  neck,  front  of 
chest,  and  upper  limb.  QZdema,  cyanosis,  epistaxis, 
meningeal  haemorrhage,  haemoptysis :  increased  action, 
or  even  hypertrophy,  of  the  heart ;  a  venous  murmur  at 


346  SURGERY    OF    THE    CHEST. 

the  upper  part  of  the  sternum,   due  to  compression  of 
the  vena  azygos. 

3.  Attacks  of  cough,  of  a  character  Hke  that  of 
whooping  cough  ;  spasmodic  asthma ;  hoarseness  or  loss 
of  voice  from  pressure  on  the  recurrent  laryngeal  nerve. 

4.  Difficulty  of  swallowing,  from  traction  on  the 
oesophagus. 

Under  the  second  division  (physical  signs)  he  in- 
cludes :  — 

1.  The  presence  of  enlarged  glands  deep  in  the 
neck. 

2.  Percussion  may  show  a  small  irregular  area  of 
dulness  in  the  sternal  or  the  interscapular  region ;  but 
this  may  be  due  in  children  to  enlargement  of  the 
thymus  gland. 

3.  Auscultation  may  detect  a  loud  blowing  sound  in 
expiration,  heard  over  the  sternum,  or  over  the  third  to 
fifth  dorsal  vertebrse. 

4.  Signs  of  perforation  into  the  oesophagus  or  the 
trachea. 

This  number  of  signs  and  symptoms  may  be  present 
in  the  last  stages  of  malignant  disease,  but  one  will  look 
in  vain  for  most  of  them  in  the  cases  that  we  are  now 
considering.  The  discussion  that  followed  Seitz's  paper 
is  to  be  noted.  Pott,  of  Halle,  laid  stress  on  the  diffi- 
culty of  distinguishing  between  enlarge-d  glands  and 
enlarged  thymus.  Fischl  (Prag)  said  that  the  diagnosis 
of  tuberculous  disease  is  greatly  strengthened  if  there  be 
enlargement  of  the  glands  on  both  sides  of  the  neck,  just 
in  front  of  the  trapezius.  He  had  often  observed  posf 
mortem  the  connection  between  these  two  sets  of  glands; 
or  one  might  remove  one  of  the  cervical  glands,  and 
examine  it  for  tubercle-bacilli.  Heubner  (Berlin)  said 
that  tuberculous  glands   in   children  are  in  most  cases 


DISEASES    OF   BRONCHIAL    GLANDS,    ETC.      347 

equivalent  to  incipient  phthisis  in  adult  life ;  the  disease 
in  children  begins  in  the  glands  rather  than  in  the 
lungs.  He  advised  that  the  diagnosis  should  be  settled 
by  the  use  of  Koch's  fluid.  Eisenschitz  (Vienna)  drew 
attention  to  the  close  connection  between  disease  of 
these  glands  and  whooping-cough.  Enlargement  of  the 
glands  may  give  rise  to  symptoms  like  those  of  whooping- 
cough,  and  a  long  attack  of  whooping-cough  may  cause 
enlargement  of  the  glands,  but  this  is  not  necessarily 
tuberculous,  and  the  glands  may  go  down  when  the  cough 
stops.  Kassowitz  (Vienna)  said  that  in  children  under  2 
years  old,  rarely  in  older  children,  a  condition  may  occur 
which  is  often  mistaken  for  enlargement  of  the  bronchial 
glands  :  a  loud  protracted  in-and-out  respiratory  sound, 
without  dyspnoea,  often  audible  at  some  distance,  and 
entirely  disappearing  during  sleep.  ^  All  the  children 
show  the  skull-changes  of  rickets.  Probably  it  is  a  reflex 
disturbance,  a  spasm  of  the  bronchial  tubes,  depending 
like  laryngismus  stridulus,  and  other  allied  states,  on  the 
rickety  changes  at  the  base  of  the  skull.  Wiederhofer 
(Vienna)  said  that  one  of  the  most  important  signs  is 
an  abnormally  loud  expiratory  sound,  heard  more  clearly 
over  the  left  bronchus  than  over  the  right ;  and  that  one 
may  sometimes  find  an  area  of  dulness  even  in  the  earlier 
stages  of  the  disease. 

These  opinions  show  the  great  difficulty  of  diagnosing 
tuberculous  disease  of  the  bronchial  and  mediastinal 
glands  in  children,  at  the  time  when  there  is  still  some 
hope  that  it  may  be  arrested  by  putting  the  child  in  the 
best  possible  conditions   for  recovery.      But  when  per- 

'  Dr.  Gee  (St.  Bart.  Hospl.  Reports,  1884,  p.  14)  has  des- 
cribed a  somewhat  similar  sound,  under  the  title  "  Respiratory 
Croaking  of  Babies."  In  a  case  of  this  kind.  Dr.  Lees  found  the 
epiglottis  folded  inward,  so  that  its  sides  almost  touched  ("Path. 
Soc.  Trans.,"  1883). 


348  SURGERY    OF    THE    CHEST. 

foration  has  been  set  up,  the  character  ot  the  case  is 
changed,  and  it  is  likely  to  come  in  need  of  surgical 
treatment. 

The  records  of  the  disease,  from  this  point  ot  view, 
are  extensive,  and  very  discouraging.  In  several  cases, 
death  has  occurred  almost  at  once ;  the  child  has  been 
in  fair  health,  with  only  a  cough  and  a  little  fretting  and 
feverishness,  and  then  has  suddenly  become  suffocated, 
and  has  died  in  a  few  hours  or  minutes.  In  others,  time 
has  been  given  for  tracheotomy,  which  yet  has  failed  to 
save  life.  In  others,  the  disease,  after  perforation,  has 
invaded  the  posterior  mediastinum  and  the  lungs,  giving 
rise  to  signs  like  those  of  empyema;  or  has  infected  the 
lungs  with  tuberculous  phthisis.  In  one,  a  boy  1 1  years 
old,  the  gland  was  coughed  up  through  the  mouth, 
and  the  patient  recovered.  These  tuberculous  glands  of 
children  rarely  break  into  the  oesophagus  or  great  vessels.^ 
From  the  point  of  view  of  surgery,  the  cases  divide 
themselves  into  those  where  tracheotomy  has  been 
performed,  and  those  where  the  chest-wall  has  been 
incised. 

Tracheotomy,  of  course,  is  not  likely  to  save  the  child. 
The  three  following  cases"  are  of  special  interest : — 

I.  A  child,  three  years  old,  had  for  some  weeks  been 
subject  to  sudden  attacks  of  dyspnoea,  lasting  from  two  or 
three  minutes  to  half  an  hour,  with  cold  sweats,  duskiness, 
and  collapse  :  there  was  some  dulness  over  the  upper  part  of 
the  sternum,  and  signs  of  general  catarrhal  iDronchitis. 
During  a  severe  attack,  tracheotomy  was  performed.  Two 
days  later,   during  a   severe   fit  of  coughing,  two  or  three 

'Voelcker,  out  of  the  records  of  2,500  general  post  mortem 
examinations  at  the  Great  Ormond  Street  Hospital,  found  only  4 
instances  of  perforation  of  the  oesophagus  ;  he  gives  also  one  of 
perforation  of  the  pericardium  ;  and  Dr.  Percy  Kidd  gives  one 
of  perforation  of  a  branch  of  the  pulmonary  artery. 

^  Demme,  Beez,  Wright  of  Huddersfield. 


DISEASES    OF   BRONCHIAL    GLANDS,    ETC.      349 

spoonfuls  of  thick  greenish  caseous  pus  came  through  the 
cannula  :  it  was  found  to  contain  tubercIe-baciUi.  The  child 
was  greatly  relieved,  and  began  to  put  on  flesh  ;  but  the 
cough  continued,  and  seven  weeks  after  the  operation  there 
were  fine  moist  crepitations  in  the  lower  lobe  of  the  right 
lung,  purulent  sputa  containing  tubercle-bacilli,  finally  tuber- 
culous ulceration  of  the  tonsils,  cedema  of  the  lungs,  and  death 
about  half  a  year  after  the  tracheotomy.  The  posi  mortem 
examination  showed  a  mass  of  caseous  glands  below  the 
trachea,  with  perforation  of  the  trachea,  and  of  both  bronchi, 
and  general  wide-spread  tuberculosis  through  the  whole 
body :  the  submaxillary  glands  also  were  caseous. 

2.  A  child,  5  years  old,  was  admitted  to  Hospital,  with 
acute  dyspnoea  and  stridor  :  she  had  been  subject  to  similar 
attacks  for  the  last  year  and  a  half.  Respiration  20,  with 
marked  dyspnoea,  loud  stridor,  and  violent  inspiratory  effort ; 
pulse  120,  temp.  io2'2°;  no  dulness  anywhere  on  percussion, 
coarse  crepitations  heard  behind  ;  one  enlarged  cervical 
gland,  and  a  soft  swelling  just  above  the  sternum,'  rising  in 
expiration,  disappearing  in  inspiration,  giving  no  emphy- 
sematous crackling.  Tracheotomy  was  done  a  few  hours 
after  admission.  As  soon  as  the  deep  fascia  was  opened,  it 
was  found  that  the  swelling  in  the  neck  was  due  to  emphy- 
sema :  air  bubbled  up  with  each  expiration,  and  could  clearly 
be  heard  whistling  in  and  out  of  the  air-passages.  The 
trachea  was  now  opened,  and  a  stream  of  thin  pus  ran  out 
of  it ;  the  source  of  it  could  not  be  made  out  ;  no  tubercle- 
bacilli  were  found  in  it.  On  the  third  day  after  the  operation, 
the  child  came  out  in  a  scarlatinal  rash,  and  later  had 
desquamation,  oedema,  and  ha^morrhagic  nephritis.  The 
cervical  and  submaxillary  glands  also  became  enlarged  ;  the 
emphysema  remained  for  some  weeks  ;  she  finally  made  a 
complete  recovery. 

3.  In  a  similar  case,  tracheotomy  was  performed  on 
account  of  the  urgent  dyspnoea  ;  and  as  no  relief  followed 
the  opening  of  the  trachea,  a  catheter  was  passed  down  to  its 

'  Similar  emphysema  occurred  in  one  of  the  cases  quoted  by 
Voelcker,  a  child  4  years  old,  who  had  gone  through  a  severe 
attack  of  measles  a  month  previously.  She  suffered  dyspnoea, 
and  a  swelling  suddenly  appeared  in  the  neck,  and  spread  up  to 
the  face  and  down  over  the  trunk.  With  the  onset  of  the 
emphysema,  her  breathing  was  relieved,  and  she  coughed  up  some 
pus  mixed  with  blood.  The  emphysema  and  purulent  expecto- 
ration lasted  about  three  weeks,  and  she  then  recovered. 


35°  SURGERY    OF    THE    CHEST. 

bifurcation  ;    this  caused  the  child  to  cough   up   about  an 
eggcupful  of  fcetid  pus.     Recovery. 

The  presence  of  emphysema,  of  a  dull  area,  and  of 
enlarged  glands  in  the  neck,  is  to  be  noted  in  these 
cases  ;  and  they  also  show  that  the  surgeon  ought  to 
explore  the  main  bronchi  at  the  time  of  the  operation, 
and  perhaps  also  to  fasten  the  wound  in  the  trachea  to 
the  skin.  He  must  remember,  also,  that  the  gland  may 
be  impacted  in  the  glottis.  But  of  course  the  exploration 
of  the  bronchi  will  lead  to  nothing  if  the  dyspnoea  be 
due  to  simple  compression  without  ulceration,  or  rather 
to  simple  compression  plus  muscular  spasm  of  the 
bronchial  tubes.' 

Incision  through  the  chest-wall  may  be  illustrated  by 
the  two  following  cases  : — 

I.  A  little  boy,  about  4  years  old,  was  admitted  to 
Hospital,  having  been  ailing  for  six  weeks:  cough  during 
the  latter  part  of  this  time,  and  vomiting  during  the  last  few 
days.  There  was  some  dulness  over  the  left  side  of  the 
chest,  with  loss  of  vocal  vibration,  and  impaired  vocal  reso- 
nance ;  breath  sounds  weak  above,  absent  below.  Pus 
was  found  with  the  exploring  needle,  but  next  day  resection 
of  rib  and  incision  of  pleura  failed  to  find  pus  or  to  open 
any  cavity  in  the  lung.  A  month  later,  the  vomiting  re- 
turned, and  on  one  occasion  he  brought  up  blood  ;  the  signs 

'^  It  may  be  well  to  note  here  the  possibility  of  treating  certain 
cases  of  stricture  of  the  trachea  or  bronchi  by  the  use  of  bougies. 
Seifert  (Ueber  Tracheo-broncho-stenose  und  deren  Abhandlung, 
"  Wien.  Klin.  Wchnschr."  1894,  P-  95o)>  gives  the  case  of  a  man, 
aged  43,  with  signs  of  stricture  of  the  trachea  in  two  places,  and 
of  the  left  bronchus.  Having  treated  the  tracheal  strictures  with 
bougies,  he  passed  an  English  oesophageal  bougie,  9  size,  a  dis- 
tance of  17^  or  1 8  inches  from  the  teeth.  '  The  patient  declared 
with  confidence  (!)  that  the  bougie  had  passed  into  the  lower  lobe 
of  the  left  lung.'     Some  improvement  followed. 

We  may  also  note  that  it  is  just  possible  for  extreme  dilatation 
of  the  left  auricle  to  cause  narrowing  of  the  left  bronchus.  Two 
cases  of  this  are  recorded  by  Dr.  H.  H.  Taylor  and  Dr.  Lee 
Dickinson,  "Path.  Soc.  Trans.,"  1S89  and  1893. 


DISEASES    OF   BRONCHIAL    GLANDS,    ETC.      351 

of  disease  in  the  lung  became  more  marked,  and  he  died 
suddenly,  six  weeks  alter  admission,  with  hemorrhage  by 
the  mouth  and  from  the  bowels.  The ^os/  vwrtciii  examina- 
tion showed  the  lung  to  be  adherent  and  gangrenous  at  the 
seat  of  operation,  with  tuberculous  consolidation  of  its  upper 
lobe;  a  mass  of  caseous  glands  had  perforated  the  left 
bronchus,  and  the  anterior  surface  of  the  oesophagus  was 
perforated  in  two  places.  There  was  recent  dark  blood-clot 
in  the  stomach  and  intestines,  and  there  were  caseous  glands 
in  the  neck. 

2.  A  child,  aged  5  years  and  9  months,  was  admitted  to 
Hospital  with  signs  of  a  cavity  in  the  posterior  part  of  the 
right  lung  ;  fever,  haemoptysis,  and  fcetor  of  breath.  Resec- 
tion was  made  of  the  sixth  and  seventh  ribs  in  the  right 
interscapular  region  ;  the  lung  was  adherent,  but  repeated 
exploratory  punctures  failed  to  find  any  cavity  in  it.  The 
child  died  a  few  hours  after  operation.  The  post  viortein 
examination  showed  an  abscess  the  size  of  a  walnut,  invading 
the  root  of  the  right  lung,  and  opening  into  the  right  bron- 
chus ;  there  were  caseous  glands  close  to  it,  but  no  tuber- 
culous disease  elsewhere  ;  several  patches  of  gangrene  in 
the  lung. 

We  have  now  gone  through  the  chief  affections,  ex- 
cluding malignant  disease,  of  these  glands  and  of  the 
posterior  mediastinum.  We  have  still  to  take  note  of 
the  anatomical  observations  recently  published  as  to  the 
best  method  of  exposing  and  opening  the  mediastinal 
space. 

These  observations  have  been  made  chiefly  to  find 
what  hope  we  have  of  removing  foreign  bodies,  by  this 
method,  from  the  oesophagus  or  the  bronchi.  The 
removal  of  such  bodies  from  the  bronchi  by  direct 
incision  has  been  proved,  as  we  shall  see- in  the  next 
chapter,  10  be  almost  impossible ;  it  is  one  of  the  most 
dangerous  operations  ever  devised.  The  removal  of 
foreign  bodies  from  the  oesophagus  belongs  rather  to 
general  surgery;  at  all  events,  I  do  not  know  that  the 
posterior  mediastinum  has  yet  been  opened  for  any 
operation  of  this  kind. 


352  SURGERY    OF    THE    CHEST. 

Three  series  of  dissections'  have  been  made  lately  on 
the  surgical  anatomy  of  this  region  ;  and  I  give  at  some 
length  an  account  of  two  of  them. 

QUENU    AND    HaRTMANN'S    OBSERVATIONS,     1 89 1. 

'  We  thought  at  first  that  one  ought  to  keep  as  close  as 
possible  to  the  spine,  dividing  the  ribs  close  to  the 
transverse  processes  of  the  vertebrae ;  but  we  soon  found 
this  plan  a  bad  one,  because  the  bodies  of  the  vertebrse 
push  the  aorta  and  the  oesophagus  too  far  forward.  It  is 
infinitely  better  to  make  the  incision  well  away  from  the 
spine,  and,  as  nearly  as  possible,  level  with  a  line  drawn 
across  the  back  wall  of  the  mediastinum.  The  best  way 
is  to  divide  the  ribs  at  their  angles. 

'  We  therefore  recommend  the  following  operation  : — 
A  vertical  incision,  6  inches  long,  over  the  angles  of  the 
ribs,  about  4  fingers'  breadth  from  the  spine,  with  its 
centre  level  with  the  spine  of  the  scapula,  or,  better  still, 
with  a  point  a  little  below  it.  By  retracting  the  lower 
edge  of  the  trapezius  upward  and  inward,  one  need  only 
divide  a  few  fibres  of  this  muscle.  Next,  one  divides  the 
rhomboideus,  and  gets  to  the  outer  side  of  the  deep 
muscles  of  the  spine ;  these  may  be  left  undisturbed. 
The  ribs  are  then  cleaned  and  resected,  about  2  inches 
of  each.  This  amount  of  resection,  of  three  ribs  only, 
allows  you,  after  stripping  up  the  pleura,  to  get  your 
whole  hand  into  the  posterior  mediastinum.  It  has  been 
suggested  that  one  ought  to  turn  back  the  divided  pieces 

'  Nosiloff,  "  Qisophagotomia  et  resectio  oesophagi  endotho- 
racica,"  1888  ;  Quenu  and  Hartmann,  "  Des  voies  de  penetration 
chirurgicale  dans  le  mediastin  posterieur,"  Soc.  de  Chir.,  Paris, 
1891;  Josepli  Bryant,  "The  surgical  technique  of  entry  to  the 
posterior  mediastinum,"  Trans.  Amer.  Surg.  Ass.,  1895,  P-  443- 
A  short  account  of  Nosiloff 's  paper  is  given  in  the  "Annals  of 
Surgery,"  1889. 


DISEASES   OF   BRONCHIAL    GLANDS.    ETC.      353 

of  ribs,  instead  of  removing  them,  but  this  merely  com- 
phcates  the  operation,  and  is  not  necessary.  We  need 
not  say  that  all  bleeding  must  be  stopped,  and  the 
intercostal  vessels  must  be  ligatured. 

'  In  this  way,  you  make  an  opening  into  the  chest, 
measuring,  from  the  second  rib  to  the  upper  border  of 
the  sixth,  4  to  5  inches  in  length  ;  and  if  you  draw  the 
ribs  outward,  you  can  see  and  explore  the  root  of  the 
lung,  the  aorta,  and  all  that  part  of  the  oesophagus  that 
lies  between  the  bronchi  and  the  diaphragm.  If  you 
incise  the  pleura  instead  of  stripping  it  off  the  ribs,  you 
can  reach  the  upper  lobe  of  the  lung,  and  even  the 
highest  point  of  the  pleural  cavity,  much  more  easily 
than  by  the  anterior  resection  lately  recommended  in 
Germany  for  opening  apical  cavities. 

'We  do  not  know  what  will  be  the  practical  applications 
of  these  observations  :  a  prion  they  seem  to  us  to  justify 
interference  in  cases  of  injury  of  the  bodies  of  the 
vertebrae,  mediastinal  abscess,  and  compression  of  the 
bronchi  or  the  oesophagus  by  certain  glandular  swellings. 
But,  above  all,  they  will,  we  think,  be  useful  for  the 
treatment  of  certain  affections  of  the  oesophagus,  especi- 
ally for  the  removal  of  foreign  bodies  which  cannot 
otherwise  be  removed.  We  know  that  there  is  no  slight 
risk  in  pushing  them  into  the  stomach  ;  out  of  22  patients 
thus  treated,  8  died.  And  we  should  prefer  our  opera- 
tion to  Pvichardson's,  where  you  open  the  stomach, 
introduce  your  whole  hand,  and  pass  instruments  up  the 
oesophagus  from  below.' ^ 


'  Quenu  and  Hartmann  draw  attention  to  the  fact  that  the 
right  pleura  passes  sHghtly  beyond  the  middle  line,  forming  a 
cul-de-sac  between  the  aorta  and  the  oesophagus ;  the  posterior 
mediastinum  should  therefore  always  be  approached  from  the 
lelt  side. 

23 


354  SURGERY    OF    THE    CHEST. 

Bryant's  Observations,   1895. 

'  The  patient  should  be  placed  obliquely  on  the  abdo- 
men, with  the  shoulders  so  supported  as  to  cause  the 
least  possible  interference  with  the  movements  of  the 
thorax,  and  with  the  arm  hanging  over  the  table  so  as  to 
draw  the  scapula  as  far  outward  as  possible.  The  centre 
of  the  field  of  operation  should  correspond  to  the  seat 
of  obstruction.  The  tip  of  a  spinous  process,  in  this 
part  of  the  spinal  column,  is  opposite  to  the  rib  of  the 
next  vertebra  below ;  and  therefore  the  tip  of  a  spinous 
process  will  indicate  the  rib  at  the  centre  of  the  field  of 
operation. 

'A  flap  three  inches  square,  including  the  tissues  down 
to  the  ribs,  and  reflected  inward,  affords  ample  space. 
Portions  of  not  less  than  three  ribs  must  be  displaced, 
from  their  angles  to  the  outer  extremities  of  the  trans- 
verse processes.  The  middle  one  of  the  three  must  be 
carefully  exposed  with  a  raspatory ;  the  pleura  must  be 
stripped  off  it  by  means  of  a  silk  thread  passed  with  an 
aneurysm-needle  between  the  rib  and  the  pleura,  and 
worked  to  and  fro  so  as  to  loosen  the  pleura ;  the  rib  is 
then  divided  with  a  chain-saw,  and  removed,  and  its 
vessels  ligatured.  The  pleura  is  then  very  carefully 
stripped  from  the  rib  above  and  the  rib  below :  this  must 
be  done  with  the  fingers  only,  and  during  expiration 
only;  then  these  ribs  are  divided,  and  turned  upward 
and  downward,  but  not  removed.  The  separation  of  the 
pleura  from  the  ribs,  bodies  of  the  vertebras,  etc.,  must 
be  conducted  with  great  care;  if  a  rent  takes  place,  it 
must  be  closed  at  once.  If  the  pleura  be  gently  pushed 
outward,  the  movements  of  a  bougie  in  the  oesophagus 
can  be  clearly  seen  ;  a  strong  electric  light  is  a  very 
important    aid.       Below    the    arch    of    the    aorta,    the 


DISEASES   OF   BRONCHIAL    GLANDS,    ETC.      355 

oesophagus  is  reached  better  from  the  right  side ;  above 
the  arch,  it  can  be  reached  from  either  side,  but  better 
from  the  left.' 

Such  are  the  two  operations  suggested,  from  anatomi- 
cal observations,  for  opening  the  posterior  mediastinum. 
It  will  be  noted  that  they  have  been  planned  rather  for 
the  removal  of  foreign  bodies  than  for  the  relief  of 
suppuration.  They  do  not  agree  well  together,  and  it  is 
certain  that  either  of  them  would  be  attended  by  grave 
difficulties,  and  would  often  be  followed  by  death.  It 
is  indeed  rather  bewildering  to  find  this  sentence  in  Mr. 
Bryant's  essay — •'  Suffice  it  to  say,  that  the  venae  azygos, 
the  aorta,  and  the  pulmonary  vessels,  along  with  the 
pneumogastric  nerves,  ffmsf  be  courteously  approached  and 
considerately  treated.'  Most  of  us  would  wish  to  show 
our  courtesy  and  consideration  toward  these  structures 
in  some  other  way  than  by  approaching  and  treating 
them.  Still,  the  operation  is  possible,  and  I  think  it 
would  be  justified  for  the  saving  of  life  in  septic  or 
gangrenous  inflammation  of  the  posterior  mediastinum. 

Note. — Cases  of  fatal  mediastinal  abscess  from  sword- 
swallowing,  and  from  foreign  body  impacted  in  the 
oesophagus,  are  recorded  by  Dr.  Charles  Gross  and  Dr. 
Sharkey,  in  the  "  Transactions  of  the  Pathological 
Society,"  for  1885.  In  the  "Society's  Transactions," 
for  1887.  Dr.  Lauriston  Shaw  has  recorded  a  case  of 
bronchiectatic  cavity  in  the  lung,  from  impaction  of  a 
tuberculous  bronchial  gland,  in  a  child  only  two  years 
old. 


35^ 


CHAPTER  XXIII. 

FOREIGN  BODIES  IN  THE  AIR-PASSAGES. 

Clinical  records  of  the  signs,  treatment,  and  results  of 
foreign  bodies  in  the  air-passages  are  common  in  the 
hterature  of  surgery ;  and  the  statistics  of  operation  are, 
on  the  whole,  very  good.  But  in  addition  to  all  the 
manoeuvres  practised  at  the  time  of  tracheotomy,  or  after 
it,  we  have  to  consider  the  advice  given  us  of  late  years, 
that  in  certain  desperate  cases  an  attempt  should  be  made 
to  reach  the  foreign  body  either  from  the  front  of  the 
chest,  or  through  the  substance  of  the  lung,  or  by  ex- 
posing the  main  bronchus  from  behind  in  the  posterior 
mediastinum. 

Reversing  the  natural  order  of  things,  let  us  first  try  to 
estimate  the  value  of  these  proposed  new  methods,  and 
then  take  a  general  view  of  the  whole  subject,  and  of  the 
advantages  gained  by  tracheotomy  with  exploration  of  the 
bronchi.  Of  course  the  new  proposals  apply  only  to 
cases  where  tracheotomy  and  all  attempts  to  remove  the 
foreign  body  through  the  trachea  have  failed,  and  there 
is  active  mischief  in  the  lung. 

I.  Dr.  Rushmore,^  in  a  case  of  this  kind,  endeavoured 
to  reach  the  bronchus  through  the  front  wall  of  the  chest; 
he  turned  down  a  flap  3  inches  square,  cut  through  the 
pectoral  muscle,  drew  it  out  of  the  way,  and  was  about 
to  make  resection  of  the  ribs  when  the  patient's  condition 
became  so  bad  that  the  operation  had  to  be  abandoned. 

'  "  New  York  Medical  Journal,"  July,  1891. 


FOREIGN   BODIES   IN   THE   AIR-PASSAGES.      357 

His  account  of  the  case  is  full  of  interest :  I  have  noted 
it  further  on.  I  have  found  no  record  of  any  other 
attempts  to  reach  a  foreign  body  by  this  method. 

2.  True  suggests  that  in  a  desperate  case  an  attempt 
should  be  made  to  reach  it  through  the  thickness  of  the 
lung.  '  When  all  other  methods,  including  tracheotomy, 
have  failed — when  the  patient  is  in  danger  of  death — 
when  percussion  and  auscultation  give  unmistakable 
evidence  of  a  foreign  body  in  the  lung-tissue — then  have 
we  not  the  right  to  go  straight  for  it  through  the  chest 
wall  ?  If  you  know  accurately  where  it  is,  you  cannot 
hesitate  what  to  answer — you  must  operate.  I  know  that 
the  localization  of  the  foreign  body  is  full  of  difficulties, 
but  they  do  not  seem  to  me  necessarily  insuperable.  In 
some  cases,  inflammation  of  the  lung — more  or  less  severe, 
more  or  less  extensive— may  give  us  the  guidance  that  we 
so  sorely  need  :  auscultation  and  percussion  may  tell  us 
the  position  of  the  enemy  ;  the  patient  himself  may  refer 
his  pain  to  one  particular  place.  Finally,  exploratory 
punctures,  made  with  a  light  hand  and  a  good  judgment, 
may,  in  some  cases,  justify  operation.  If  you  go  carefully 
and  use  the  cautery,  the  danger  will  not  be  excessive  : 
and  it  is  your  patient's  last  hope.  I  admit  that  incision 
of  the  lung  for  a  foreign  body  in  it  is  only  applicable  to 
this  or  that  exceptional  case :  the  localization  must  be 
exact,  the  patient  must  be  in  danger  of  death :  then,  I 
think,  you  ought  to  do  it.' 

3.  The  proposal  to  reach  the  main  bronchi  from  be 
hind  is  supported  by  those  who  have  studied  the  surgical 
anatomy  of  the  posterior  mediastinum,  and  I  have  given 
their  methods  in  Chapter  xxii.  It  sounds  so  easy  as  one 
reads  it.  '  The  bronchus  can  be  easily  felt  by  the  finger: 
the  incomplete  rings  are  so  characteristic  that  nothing 
else  can  be  mistaken  for  it.     The  incision  for  removal 


358  SURGERY    OF    THE    CHEST. 

should  be  made  in  the  long  axis  of  the  tube,  and  of  suffi- 
cient length  to  permit  the  removal  of  the  foreign  body 
without  laceration.  The  tube  should  not  be  closed :  if 
this  be  done,  it  will  surely  open  again  :  an  iodoform  tam- 
ponade, supplemented  with  drainage  tubes,  will  meet  the 
requirements  of  the  case.' 

Putting  aside  for  the  present  the  route  advised  by  True, 
we  have  here  two  American  surgeons,  one  attempting 
operation  from  the  front,  the  other  advocating  it  from 
behind.  Let  us  contrast  with  their  views  the  teaching 
and  experiments  of  Dr.  Willard,  of  Philadelphia  i  :  and  I 
make  no  apology  for  giving  a  full  abstract  of  his  work, 
because  it  seems  to  me  of  the  very  highest  practical  value. 
First,  we  may  take  his  conclusions:  next,  the  experiments 
which  led  to  them. 

1.  The  collapse  of  the  lung,  when  the  chest  is  opened, 
is  an  exceedingly  serious  and  dangerous  element  in  the 
operation,  adding  greatly  to  the  previous  shock,  and 
threatening  at  once  to  overpower  the  patient. 

2.  The  difficulties  of  reaching  the  bronchus,  especially 
upon  the  left  side,  are  exceedingly  great :  and  the  risks  of 
haemorrhage  are  enormous.- 

3.  Incision  into  the  bronchus  necessarily,  after  closure 

'Dr.  de  Forest  Willard,  "  Intra-Thoracic  Surgery:  Broncho- 
tomy  through  the  Chest-wall  for  Foreign  Bodies  impacted  in  the 
Bronchi."  "Trans.  Amer.  Surg.  Ass.,"  1891,  ix.,  p.  345.  It 
will  be  noted  that  his  experiments  were  not  much  concerned  with 
the  method  of  opening  the  posterior  mediastinum  without  opening 
the  pleura.  But  this  method  still  involves  the  risk  of  frightful 
haemorrhage :  the  opening  of  the  pleura  is  only  one  of  many 
dangers.  , 

=  '  In  a  dog,  the  aspects  of  the  parts  during  life  and  after  death 
are  as  absolutely  different  as  they  can  possibly  be.  A  bronchus 
which  after  death  is  easily  exposed  and  reached  I  have  seen,  five 
minutes  previously,  absolutely  enclosed  with  huge  pulsating 
vessels,  any  one  of  which,  if  punctured,  would  seriously  compli- 
cate the  operation,  if  not  causing  death.  The  difference  of  the 
parts  in  life  and  in  death  can  only  be  appreciated  when  seen.' 


FOREIGN  BODIES  IN   THE  AIR-PASSAGES.      359 

of  the   wound   in   the    chest-wall,    leads   to   increasing 
pneumothorax. 

4.  The  delays  in  the  operation  from  the  collapse  of 
the  patient  must  necessarily  be  great.  Rapid  work  is 
impossible,  when  the  root  of  the  lung  is  being  dragged 
backward  and  forward  at  least  half-an-inch  in  the  efforts 
occasioned  by  air-hunger,  and  precision  is  almost  im- 
possible. 

5.  To  reach  the  bronchus  is  sometimes  feasible  :  but 
to  extract  a  foreign  body  from  it,  and  to  secure  the 
patient's  recovery,  is  as  yet  highly  problematical,  and  will 
require  many  advances  in  technique.  The  anatomical 
surroundings  are  those  most  essential  to  life. 

I  give  an  abstract  of  Dr.  Willard's  experiments  on 
dogs  :  they  show  clearly  that  incision  of  a  bronchus  is 
an  impossible  operation. 

1.  Under  the  anaesthetic,  before  the  operation  was  begun, 
the  dog  ceased  to  breathe,  and  could  not  be  restored  to  life. 
The  trachea  was  opened,  and  a  pebble  was  passed  down  into 
the  left  bronchus.  Search  was  everywhere  made  for  it,  both 
in  the  bronchus  and  in  the  substance  of  the  lung,  but  in  vain. 
Finally,  it  was  found  in  the  larynx. 

2.  Incision  far  back  toward  spine,  so  as  to  reach  bronchus 
from  behind  :  free  bleeding  from  erector  spinse.  Subperios- 
teal resection  of  fourth  and  fifth  ribs,  an  inch  and  a  half  of 
each.  Tracheotomy  done,  and  a  pebble  carried  down  with  the 
forceps,  and  dropped  into  the  right  bronchus.  Pleura  opened: 
lung  immediately  collapsed,  and  the  animal's  condition  be- 
came so  bad  that  it  died  before  the  bronchus  could  be  opened. 
The  pebble  was  clearly  felt  in  the  bronchus  during  the  opera- 
tion, but  after  death  was  found  in  the  larynx.' 

3.  Incision  far  back  on  right  side,  two  inches  outside 
spine,  so  as  to  avoid  erector  spinae  :  subperiosteal  resection 
of  one  rib.     Pleura  opened  :   lung  collapsed,  and  the  animal 

^  '  By  what  means  it  had  worked  its  way  there  could  not  be 
ascertained.  Farier  and  Sabatier,  in  similar  experiments  on  dogs, 
found  that  the  objects  were  always  expelled  after  tracheotomy 
(whether  the  animal  were  lying  down,  or  upright),  even  when 
they  had  been  pushed  well  down  into  the  bronchus.' 


36o  SURGERY    OF    THE    CHEST. 

nearly  died.  Artificial  respiration  had  to  be  done  again  and 
again  :  it  was  not  possible  to  keep  him  on  his  back  :  tracheo- 
tomy and  introduction  of  a  foreign  body  were  therefore 
abandoned.  Upper  lobe  of  right  lung  drawn  forward,  bron- 
chus cleared  of  vessels  surrounding  it,  and  incised  for  half  an 
inch  :  very  free  haemorrhage  from  wound  of  a  pulmonary 
vein.  This  was  ligatured,  and  incision  in  bronchus  was 
closed  with  three  catgut  sutures.  Dog  did  well  for  two  days, 
then  died  :   cause  of  death  not  known. 

4.  Incision  in  third  left  space,  in  axillary  line :  subperiosteal 
resection  of  four  inches  of  fourth  rib.  Pleura  opened,  upper 
lobe  of  lung  drawn  out,  and  rush  of  air  into  pleura  checked  by 
passing  lobe  of  lung  through  a  slit  in  a  sheet  of  rubber-tissue: 
bronchus  exposed  outside  this  sheet.  It  was  bare  of  vessels, 
and  was  quickly  and  easily  incised.  One  stitch  was  placed 
in  the  incision  with  a  curved  palate-needle.  As  the  second 
stitch  was  being  placed,  a  sudden  movement  of  the  root  of 
the  lung  made  the  needle  enter  a  pulmonary  vein,  and  there 
was  a  gush  of  blood.  The  vein  was  seized  and  tied :  but 
further  attempts  to  close  the  wound  caused  further  hsemor- 
rhage  :  the  blood  ran  into  the  bronchus,  and  finally  the  dog 
was  killed. 

5.  Incision  on  the  left  side,  subperiosteal  resection  of 
seventh  rib  (should  have  been  a  little  higher)  :  pleura  opened, 
same  use  of  rubber-tissue.  Anterior  aspect  of  left  upper 
bronchus  exposed,  and  thoroughly  isolated,  and  free  for 
incision,  when  the  animal  suddenly  died. 

6.  Incision  on  the  right  side,  subperiosteal  resection  of 
fifth  rib  :  serious  hjemorrhage  from  intercostal  artCiy,  finally 
stopped  by  ligature.  Bronchus  of  first  lobe  inaccessible  both 
in  front  and  behind,  being  deeply  concealed  and  covered  with 
pulmonary  vessels.  Bronchus  of  second  lobe  reached,  in  front, 
and  incised  for  one-third  of  an  inch.  Three  catgut  sutures 
successfully  placed,  but  the  animal  had  repeatedly  to  be  re- 
suscitated with  artificial  respiration,  and  died  15  minutes 
after  the  operation. 

7.  Incision  on  the  left  side,  subperiosteal  resection  of  fourth 
rib  :  pleura  opened,  immediate  collapse  of  lung,  and  great 
shock.  Bronchus  of  upper  lobe  found  concealed  by  enormous 
pulmonary  arteries  and  two  huge  veins  which  lay  in  front, 
completely  covering  it.  These  were  carefully  isolated,  but 
the  great  depth  of  the  bronchus  made  incision  of  it  quite 
impossible,  as  the  vessels  could  not  be  held  out  of  the  way. 
Bronchus  of  middle  lobe  exposed  from  behind:  but  aorta  and 
pneumogastric  lay  upon  it,  so  that  incision  seemed  hopeless. 


FOREIGN   BODIES   IN   THE   AIR-PASSAGES.      361 

It  was  at  last  achieved :  one  suture  was  placed,  the  next  tore 
out ;    and  the  dop^,  after  repeated  resuscitation,  finally  died. 

8.  Incision  on  the  right  side  :  resection  of  an  inch  and  a 
half  of  filth  rib:  pleura  opened,  upper  bronchus  exposed: 
bronchial  and  pulmonary  veins  pushed  aside:  very  large 
vena  azygos.  Bronchus  incised  for  one  third  of  an  inch:  no 
sutures,  so  that  effect  of  open  wound  of  bronchus  might  be 
observed.  Rapid  pneumothorax,  air  soon  bursting  through 
superficial  wound.  When  this  was  finally  closed,  pneumo- 
thorax became  more  intense,  and  soon  ended  in  death.  The 
slit  in  the  bronchus  acted  like  the  valve  of  a  force-pump. 

These  very  valuable  experiments  plainly  forbid  all 
hope  of  our  reaching  and  removing  foreign  bodies  in 
the  bronchi  by  any  direct  incision  of  them.  It  is  true 
that  one  might  possibly  gain  access  to  a  bronchus  through 
the  posterior  mediastinum  without  opening  the  pleura,  or 
at  all  events  without  causing  collapse  of  the  lung  :  but  the 
dangers  of  haemorrhage  are  so  great,  and  the  uncertainty 
of  the  whole  procedure  so  frightful,  that  the  operation  is 
hardly  likely  ever  to  be  practised.  And  how  can  the 
surgeon  explore  the  bronchus,  or  get  a  hold  on  the  foreign 
body,  through  a  button-hole  in  the  bronchus  deep  inside 
the  chest  ?  How  can  he  close  his  incision,  even  if  he  can 
make  it  ?  And  how  can  he  prevent  infection  of  the  medi- 
astinum, if  he  leaves  it  open?  These  objections  may  be 
theoretical :    but  so  is  the  operation. 

Truc's  method  seems  to  me,  on  the  whole,  the  least 
dangerous  of  the  three.  It  is  indeed  hardly  more  than  an 
early  attempt  to  reach  a  suppurating  cavity  deep  in  the 
lung.  There  is  not  much  difference  between  incising 
the  lung  to  find  a  foreign  body  in  it,  and  opening  a 
deep  gangrenous  cavity  caused  by  the  falling  of  the 
stump  of  a  tooth  into  the  air-passages  (see  Dr.  Strange's 
case,  p.  310).  It  would  be  necessary  to  make  a  free 
resection,  to  shut  off  the  pleural  cavity  by  some  such 
method  as  Roux's  suture,  given  on  p.  308 ;  and  to  make 


362  SURGERY    OF    THE    CHEST. 

very  careful  search  in  the  lung-tissue  with  a  long  fine 
needle.  Probably  the  operation  would  fail.  Possibly 
incision  of  the  lung  with  a  Paquelin's  cautery  might  pro- 
mote escape  of  the  foreign  body  some  time  after  the 
operation.  It  is  in  the  lung  that  the  chief  harm  is  being 
done  :  it  is  the  state  of  the  lung  that  gives  the  indica- 
tions for  operation,  if  any  sort  of  operation  is  justifiable. 
Leaving  these  desperate  cases,  and  their  desperate 
remedies,  we  come  to  the  general  signs  and  course  of 
foreign  bodies  in  the  air-passages,  and  to  the  results 
gained  by  tracheotomy  and  by  exploration  of  the  bronchi 
from  the  trachea. 

General  Signs  and  Course. 

The  list  of  the  dififerent  things  that  have  found  their 
way  into  the  air-passages  is  too  long  to  be  put  here. 
Some  of  them,  such  as  beans  and  other  seeds,  may  swell 
and  so  become  fixed:  but  the  swelling  of  the  mucous 
membrane  of  the  bronchus  is  more  to  be  feared  than  the 
swelling  of  the  foreign  body.  The  history  of  the  accident 
must  be  very  carefully  considered.  An  enlargement  of  the 
bronchial  glands  may  give  signs  like  those  of  mechanical 
obstruction,  and  vice  versa ;  an  abrasion  of  the  oesophagus 
or  of  the  trachea  may  cause  misleading  symptoms  ;  or  the 
period  of  quiet  which  sometimes  follows  the  settling  down 
of  the  intruder  may  be  taken  as  evidence  that  it  is  not 
there  at  all.  In  all  cases,  a  careful  laryngoscopic  exam- 
ination must  be  made,  and  the  surgeon  should,  if  possible, 
get  a  duplicate  of  the  thing,  and  see  what  he  can  learn 
from  it :  the  hooks  on  a  false  tooth,  or  the  shank  on  a 
button,  or  the  wool  on  the  end  of  a  'puff-dart'  may  help  or 
hinder  him  in  the  removal  of  them.  I  had  the  privilege 
of  helping  Mr.  Thomas  Smith  in  the  case  recorded  by 
him  and  Dr.  Cheadle  in  the  Transactions  of  the  Medico- 


FOREIGN   BODIES   IN   THE   AIR.PASSAGES.      363 

Chirurgical  Society  for  1888  :  the  obstruction  was  a 
metal  pencil-cap.  It  was  probable  that  the  cap  had  gone 
down  into  the  bronchus  head  foremost.  A  delicate  probe, 
passed  down  to  it  and  rotated,  gave  the  feeling  of  being 
inside  it.  A  fine  laryngeal  crocodile-forceps,  with  its  blades 
roughed  on  their  outer  aspect,  was  then  passed  down  into 
the  cap,  the  blades  were  expanded  inside  it,  and  the  cap 
was  pulled  out  fitted  tight  over  them.  Or  we  may  take, 
as  another  example  of  how  much  depends  on  the  charac- 
ter of  the  foreign  body.  Dr.  Rushmore's  case,  where  a 
cork  was  impacted  in  the  left  bronchus,  close  fitting  it. 
Tracheotomy  having  been  done,  with  division  of  the 
second,  third  and  fourth  rings  of  the  trachea,  he  attempted 
to  suck  out  the  cork  with  an  air-pump  :  this  had  promised 
well  in  experimenting  with  a  cork  lodged  in  a  piece  of  india- 
rubber  tubing,  but  now  failed  altogether.  Then  loops  of 
wire,  and  bougies  with  glue  at  the  end,  were  tried  in  vain. 
Five  days  later  he  tried  a  corkscrew  concealed  in  a  slit 
tube,  with  two  spikes  movable  between  the  screw  and 
the  tube.  He  got  the  spikes  into  the  cork  and  then 
turned  the  screw  into  it,  but  the  whole  thing  pulled  out. 
Then  the  anterior  operation  was  tried  and  abandoned. 
The  patient  died  five  days  later  with  purulent  hepatiza- 
tion of  the  lung.  Two  punctures  were  found  on  the 
cork,  and  a  small  piece  of  it  was  missing. 

For  the  general  character  of  foreign  bodies  in  the  air- 
passages,  we  have  Dr.  Weist's  ^  careful  analysis  of  no  less 
than  1000  recorded  cases.  In  America,  the  commonest 
intruder  is  a  grain  of  American  corn  :  of  177  cases,  66 
ended  in  expulsion  and  recovery,  26  died  without  opera- 
tion, and  85  underwent  tracheotomy,  of  whom  66  recover- 
ed and  1 9  died.     Water-melon  seeds  were  the  offenders 

1  "  A  Study  of  a  thousand  cases  of  Foreign  Bodies  in  the  Air- 
Passages."     "Trans.  Amer.  Surg.  Ass.,"  1881-83,  i.,  p.  117. 


364 


SURGERY    OF    THE    CHEST. 


in  109  cases  ;  70  got  well  without  operation,  5  died 
without  it,  and  34  had  tracheotomy  done,  of  whom  26 
recovered  and  8  died.  Coffee-beans  accounted  for  59, 
the  majority  recovered  without  operation.  The  cases  of 
'miscellaneous'  bodies  were  371;  of  these,  263  went 
without  operation,  and  199,  about  three  out  of  four, 
recovered :  108  had  tracheotomy,  and  77  recovered. 
His  1000  cases  give  a  total  of  93  deaths  after  tracheotomy, 
and  in  no  less  than  73  of  these,  the  foreign  body  was 
never  removed  at  all.  In  5  of  them,  it  was  spontaneously 
expelled  through  the  mouth  some  months  after  the  wound 
had  closed. 

In  63  out  of  the  1000  it  was  removed  by  methods  short 
of  tracheotomy  (forceps  and  frontal  mirror  28,  forceps 
alone  20,  probang  2,  wire-hook  3,  finger  8),  and  of  the  63 
only  I  died.  The  intruder,  in  these  63  cases,  was  in  the 
larynx  in  39,  and  in  the  trachea  in  3  only,  in  the  remain- 
ing 21  its  situation  was  not  recorded. 

The  total  number  of  operations^  was  338,  of  whom 
245  recovered  and  93  died.  The  nature  of  the  '  corpus 
delicti '  in  these  93  fatal  cases  was  as  follows  : — 


Foreign  Body. 

American  corn     . . 
Water-melon  seeds 
Beans 

Coffee-beans 
Other  seeds 
Miscellaneous 

Body  removed      Body  not  found 
Fatal  cases.                   by                         or  not 
operation.                removed. 
19           ..           6           ..           13 

8  ..           0           ..             8 
15           ..           0           ..           15 
II           . .           5           . .             6 

9  ..          I          ..            8 
31          ..          8          ..          23 

Finally,  we  have  to  note  that  in  10  of  the  patients,  the 

voice  was  lost  after 

the  operation,  and  in  38 

it  was  im- 

paired. 

^  Laryngotomy  36,  of  whom  30  recovered  and  6  died.  Laryngo- 
tracheotomy  26,  of  whom  19  recovered  and  7  died.  Tracheotomy 
276,  of  whom  196  recovered  and  80  died. 


FOREIGN   BODIES   IN   THE  AIR-PASSAGES.      365 

Of  course  it  is  only  the  worst  cases  that  come  to  opera- 
tion, and  the  dressing  and  after-treatment  of  tracheotomy 
are  better  now  than  they  were  twenty  or  more  years  ago: 
still,  these  figures  are  to  be  carefully  studied.  They  show 
that  seeds  and  grains  are  not  likely  to  do  serious  harm  in 
the  air-passages,  and  that  our  chance  of  finding  them,  if 
they  do,  is  almost  hopeless,  and  they  prove  the  need  of 
laryngoscopic  examination,  and  of  paying  great  attention 
to  the  character  of  the  foreign  body  before  deciding  to 
operate. 

The  symptoms  and  physical  signs  of  a  foreign  body  in 
the  air-passages  are  so  variable,  and  belong  so  much  more 
to  medicine  than  to  surgery,  that  I  need  not  here  quote 
long  accounts  of  them ;  but  I  give  the  signs  that  were 
noted  in  the  case  of  the  pencil-cap  in  the  left  bronchus  as 
a  good  instance  of  the  accuracy  of  localization  that  may 
in  some  of  these  cases  be  attained.  '  It  was  quite  clear 
from  the  physical  signs  that  the  left  lung  was  almost 
completely  collapsed.  The  retraction  of  the  side,  the 
absence  of  movement,  the  rising  of  the  stomach  to  the 
level  of  the  nipple,  the  displacement  of  the  heart's  apex 
upward  and  to  the  left,  showing  extreme  contraction  of 
the  lung— together  with  the  impaired  resonance  and 
vibration,  and  the  almost  complete  absence  of  respiratory 
sound — were  conclusive  on  this  point.  The  fact  that  a 
certain  amount  of  air  passed  in  and  out  of  a  portion  of 
the  upper  lobe  seemed  to  prove  that  the  pencil-cap  had 
passed  to  the  extreme  end  of  the  left  bronchus,  and  had 
therefore  gone  beyond  its  branch  to  the  upper  lobe  of  the 
lung.' 

Of  all  the  records  I  can  find,  this  case  comes  first  in 
skill,  and  forethought,  and  good  judgment.  From  the 
physical  signs  the  pencil-cap  was  exactly  localized  :  a 
preparation  was  made  of  the  lungs  and  trachea  from  the 


366  SURGERY    OF    THE    CHEST. 

dead  body,  with  a  similar  obstacle  put  inside  them.  The 
one  right  way  of  grasping  the  intruder  was  carefully 
thought  out  before-hand,  and  the  operation  was  as  accur- 
ate as  the  reasoning  that  settled  the  exact  method  of  it, 
and  was  at  once  successful. 

The  rule  that  the  right  bronchus  is  more  often  obstruct- 
ed than  the  left  is  so  often  contradicted  by  facts  that  we 
must  not  lay  stress  on  it.  Of  30  cases  given  by  Beleg,  in 
19  the  left  bronchus  was  obstructed ;  Bourdillat  gives  26 
right  and  15  left;  Gross,  24  right  and  8  left;  Cheadle, 
14  right  and  19  left ;   and  Sanders,  23  right  and  5  left. 

The  prognosis,  if  no  operation  be  done,  is  so  good  in 
some  cases  and  so  bad  in  others  that  nothing  can  be  said 
about  it.  A  water-melon  seed  is  a  very  different  thing 
from  a  cork,  or  a  tooth  with  hooks  on  it,  or  one  of  those 
needles  with  wool  at  the  end  that  children  use  for  the 
game  of  "puff-dart."  Seeds,  though  they  swell  at  first, 
become  soft  and  broken  afterward.  Some  bodies  may 
be  able  to  pierce  the  bronchi,  and  may  thus  become 
encysted  in  the  lung,  or  may  work  their  way  out  through 
it :  others,  without  irritating  or  infecting  the  lung,  may 
lie  quiet  even  for  many  years  and  then  be  at  last 
expelled  through  the  mouth.  A  hard  body  may  be  missed 
with  the  forceps,  because  it  is  covered  with  thick  tough 
mucus,  as  in  the  following  case^ : — 

'  Some  years  ago  I  was  required  to  perform  tracheotomy 
for  the  removal  of  an  artificial  tooth  with  its  attachment  from 
the  air-passages.  I  was  surprised  at  the  ease  with  which  I 
could  pass  through  the  trachea  and  reach  both  bronchi, 
especially  the  right.  The  search  was  long  and  tedious  :  I 
was  groping  in  the  bronchi,  when  the  body  was  really  at  the 
seventh  ring  in  the  trachea.  Not  finding  it  in  either  bronchus, 
1  again  introduced  the  forceps  a  short  distance,  and  slowly 

'  Dr.  Hingston,  of  Montreal;  Discussion  on  Dr.  Willard's 
paper. 


FOREIGN   BODIES   IN   THE  AIR-PASSAGES.      367 

advanced  them,  now  open,  now  closed.  In  this  way  I  found 
and  removed  a  sqfi(  body,  which  was  the  tooth  entirely 
covered  with  thick  tough  mucus.  It  had  been  in  the  trachea 
three  months.' 

We  need  not  delay  over  methods  other  than  tracheo- 
tomy, save  to  note  once  more  the  great  importance  of 
laryngoscopic  examination.  The  old  plan  of  using  snuffs 
and  emetics  was  useless  and  dangerous.  To  turn  the 
patient  head  downward  and  hit  him  on  the  back  has  in 
some  cases  produced  the  desired  result ;  but,  unless 
tracheotomy  has  already  been  done,  this  sort  of  treatment 
is  so  hazardous  that  it  should  never  be  attempted. 

1  '  On  April  3rd,  1843,  a  gentleman,  playing  with  some 
children,  put  a  half-sovereign  in  his  mouth,  and  it  slipped 
behind  his  tongue  :  violent  coughing  and  vomiting  at  once 
followed.  After  this  he  was  easy  for  a  few  days,  but  on  April 
7th  had  troublesome  cough,  sputa  tinged  with  blood,  pain  in 
right  side  of  chest.  For  the  next  two  or  three  weeks  his 
cough  was  now  better  now  worse.  He  could  feel  the  coin 
move  in  his  trachea,  and  could  make  it  slip  upward  by  invert- 
ing himself.  On  April  25th  he  was  strapped  on  a  swinging 
platform,  and  was  tilted  head  downwards,  and  then  struck  on 
the  back.  '  The  cough  was  so  distressing,  and  the  appear- 
ance of  choking  was  so  alarming,  that  it  became  evident  it 
would  be  imprudent  to  proceed  further  with  this  experiment, 
unless  some  precaution  were  used  to  render  it  more  safe.' 
On  April  27th,  Sir  Benjamin  Brodie  did  tracheotomy,  and 
attempts  were  made  that  day  and  May  2nd,  to  reach  the  coin 
with  the  forceps,  but  it  could  not  be  felt.  The  wound  was 
kept  open,  and  on  May  13th  the  patient  was  again  put  on  the 
platform  and  struck  on  the  back  ;  'presently  he  felt  the  coin 
quit  the  bronchus,  striking  almost  immediately  afterwards 
against  the  incisor  teeth,  and  then  dropping  out  of  the 
mouth.' 

2  ""A  girl,  10  or  12  years  old,  drew  a  metal  bottle-cap  into 

'  The  famous  case  of  Mr.  Brunei:  "Trans.  IMed.  Chir.  Soc," 
1843,  viii.,  p.  286.  His  surgeons  were  Sir  William  Lawrence, 
Sir  Benjamin  Brodie,  Mr.  Stanley,  Mr.  Charles  Hawkins,  and 
Mr.  Aston  Key. 

^  Dr.  Weeks,  of  Portland,  Maine;  Discussion  on  Dr.  Willard's 
paper. 


368  SURGERY    OF    THE    CHEST. 

her  air-passages :  a  few  days  later  tracheotomy  was  done.  'I 
passed  a  long  pair  of  forceps  down  and  could  feel  the  cap.  I 
worked  a  long  time — it  seemed  to  me  that  it  was  an  hour — 
but  I  failed  to  secure  it.  I  then  had  the  child  suspended,  and 
introduced  the  forceps  with  the  patient  in  this  position,  and 
after  a  few  attempts  succeeded  in  securing  the  body.' 

But  it  is  not  safe  to  try  inversion  of  the  patient  without 
tracheotomy.  And  one  case  has  been  reported  of  death 
from  hsemorrhage  during  it. 

Plate  XI.  indicates  the  collapse  of  a  part  of  the  lung, 
and  the  impaction  of  the  foreign  body  in  the  swollen 
mucous  membrane. 

Tracheotomy. 

The  incision  should  be  made  as  low  and  as  large  as  it 
can  be  without  danger,  and  the  cut  edges  of  the  trachea 
should  be  fastened  in  the  wound.  The  surgeon  should, 
if  possible,  practise  beforehand  with  various  kinds  of  for- 
ceps on  the  trachea  and  lungs  of  a  dead  body  of  the  same 
stature  as  the  patient.  I  cannot  find  that  one  is  likely  to 
succeed  with  blunt  hooks,  wire  loops,  or  scoops  ;  possibly 
a  very  small  lithotrite  might  be  found  useful.  Surgeons 
seem  to  be  agreed  that  if  the  manoeuvres  are  made  very 
lightly  and  gently  they  may  be  continued  for  a  long  time. 
We  cannot  be  bound  by  Gross's  rule,  that  only  three  at- 
tempts should  be  made,  each  lasting  only  a  minute :  very 
gentle  exploration  may  be  carried  on  for  a  very  con- 
siderable time  without  any  additional  risk  to  the  patient. 
The  surgeon  must  not  forget  to  explore  the  larynx  from 
below ;  he  may  possibly  find  the  foreign  body  above 
his  wound,  not  below  it.  Should  he  wholly  fail  to  find  or 
remove  it,  the  trachea  must  be  kept  sutured  in  the  wound, 
and  no  tube  must  be  put  in  it,  only  the  thinnest  loosest 
layer  of  gauze  must  be  laid  lightly  over  it,  and  great  care 
taken    to   keep    the    air   of  the  room    hot   and    moist. 


Plate  xi, 


'I-    •  '/ 


Ihe  Lungs  and  Air  Passages,  with  a  foreign  body  in  the  right  bronchus  of 
a  child,  5  years  old.  There  was  some  collapse  of  the  right  lower  lobe.  (From 
a  specimen  in  St.  Bartholomew's  Hospital  Museum.) 


\_Face  p.  36S. 


FOREIGN  BODIES   IN   THE  AIR-PASSAGES.      369 

Inversion  of  the  patient,  further  attempts  to  remove  the 
obstruction,  may  ultimately  succeed.  Should  everything 
fail,  and  should  the  lung  become  the  seat  of  acute  septic 
inflammation,  it  might  be  advisable  to  attempt  to  save 
the  patient's  life  after  the  method  advocated  by  True. 
We  must  remember  also  that  if  the  lung  is  already  badly 
damaged,  suppuration  or  gangrene  may  attack  it  even 
after  the  obstruction  has  been  removed. 

I  will  not  lengthen  this  chapter  with  more  quotations. 
In  those  cases  where  operation  is  necessary,  success,  if  it 
come  at  all,  will  come  not  so  much  from  depending  on 
the  experience  of  others,  as  from  carefully  studying  before- 
hand the  case  in  all  its  aspects,  from  practice  on  the  dead 
body,  and  from  the  ingenuity  and  readiness  of  the  surgeon 
himself. 


Note. — Mr.  Godlee  has  lately  read  before  the  Medico- 
Chirurgical  Society,  a  very  valuable  paper,  "  On  the 
effects  produced  by  the  retention  of  foreign  bodies  for 
lengthened  periods  in  the  bronchial  tubes."  The  follow- 
ing abstract  of  it  is  taken  from  the  "  Lancet,"  for  March 
28th,  1896.  He  quoted  several  cases  as  typical  of  the 
result  that  might  be  anticipated  if  foreign  bodies  of 
different  sorts  were  retained  for  periods  of  varying  length 
in  the  bronchial  tubes. 

1.  A  boy,  aged  16,  who  inhaled  the  peg  of  a  peg-top 
seven-and-a-half  years  before,  and  had  developed  bronchi- 
ectasis. Various  operations  were  undertaken  for  its  removal, 
and  it  was  finally  expelled  through  an  opening  made  into 
one  of  the  bronchiectatic  cavities.  The  boy  seemed  to  have 
recovered. 

2.  A  boy,  aged  6^,  who  inhaled  a  small  ivory  knob,  which 
was  retained  for  eight  weeks.  It  set  up  extensive  bronchi- 
ectasis, but  there  was  nothing  to  suggest  the  presence  of  any 
one  large  cavity,  and  thus  it  did  not  appear  that  anything 
was  likely  to  be  gained  by  surgical  interference.     The  boy 

24 


370         SURGERY    OF    THE    CHEST. 

at  first  did  not  improve,  but  later  reports  were  more  favour- 
able. 

3.  A  boy,  aged  4,  developed  bronchiectasis  as  the  result 
of  inhaling  the  vertebra  of  a  rabbit  seven  months  before.  A 
cavity  was  opened.  Ultimately,  the  bone  was  coughed  up. 
Eight  years  after  the  accident,  much  improvement  had  taken 
place,  but  there  was  still  evidence  of  a  loasic  cavity. 

4.  A  youth,  aged  17,  inhaled  an  ear  of  corn  into  one 
bronchus  :  there  followed  acute  dilatation  of  the  bronchi  and 
gangrene  of  the  lung,  with  burrowing  of  pus  ;  and  the  case 
ended  in  death. 

5.  A  case  of  bronchiectasis,  due  to  the  lodging  of  a  tooth 
in  a  bronchus.  Many  attempts  at  removal  failed,  and  the 
patient  died  of  tubercle  engrafted  on  to  the  primary  disease. 

In  the  discussion  following  Mr.  Godlee's  paper,  many 
similar  cases  were  mentioned.  Dr.  J.  K.  Fowler  observed 
that  the  lung-changes  wxre  often  extensive,  and  that  the 
bronchiectasis  was  usually  of  the  fusiform  variety,  the 
tubes  being  thickened,  and  the  surrounding  lung  indu- 
rated. The  symptoms  usually  followed  a  definite  course, 
beginning  with  cough  and  expectoration,  the  latter  be- 
coming fcetid  :  then  pleurisy  and  progressive  emaciation, 
and  later  still  diffuse  broncho-pneumonia  followed  by 
i2:angrene. 


371 


CHAPTER  XXIV. 
THE   ''SURGERY   OF   THE   HEART/' 

The  surgical  treatment  of  pericardial  effusions  is  perhaps 
the  greatest  triumph  of  all  in  the  surgery  of  the  chest, 
and  it  was  won  by  the  physicians  more  than  the  surgeons  : 
by  Trousseau  in  France,  and  by  Clifford  Allbutt  in 
England.  Though  neither  puncture  nor  incision  of  the 
pericardium  were  done  for  the  first  time  in  this  country, 
yet  we  have,  I  believe,  the  best  literature  on  the  subject : 
the  work  of  Steavenson,  Ogle,  Ewart,  and  many  others  ; 
above  all,  Dr.  Wests  admirable  monograph,  with  its 
collection  of  80  cases,  in  the  "  Transactions  of  the  Royal 
Medico-Chirurgical  Society"  for  18S3. 

The  surgery  of  the  pericardium  has  naturally  gone  on 
the  same  lines  as  the  surgery  of  the  pleura.  In  1819, 
Romero,  of  Barcelona,  operated  by  puncture  in  three 
cases,  two  of  whom  recovered.  The  next  great  advance 
was  in  1881,  when  Rosenstein,  of  Leyden,  after  twice 
puncturing  a  purulent  pericarditis,  laid  open  the  sac  and 
drained  it :  the  patient  recovered.  In  England,  puncture 
was  done  by  Jowett,  of  Nottingham,  in  1827  ;  Wheel- 
house  in  1866,  and  Teale  in  1869  ;  incision  with  drainage 
was  done  by  West  in  1882.  For  the  history  of  the 
subject,  and  for  experimental  work  on  it,  we  have 
Trousseau's  lectures,  and  a  multitude  of  scattered  writings, 
especially  during  the  last  few  years. 

But  just  as  we  have  advanced  from  the  pleura  to  the 
lung,  so  we  were  invited,  some  years  ago,  not  to  be  con- 
tent with   operations   on  the  pericardium,   but  to    look 


',72  SURGERY    OF    THE    CHEST. 

orward  to  a  time  when  we  should  operate  on  the  heart 
icself.  We  were  told  that  'heart-puncture  and  heart- 
suture  '  were  to  be  the  next  achievement  of  surgery ;  and 
it  may  be  well  to  consider  first  what  came  of  these 
promises  before  we  take  the  record  of  the  treatment  of 
pericardial  effusions  as  we  treat  pleural  effusions — the 
serous,  by  puncture  or  aspiration  ;  the  purulent,  by  in- 
cision and  drainage,  with  or  without  resection. 

Now  of  '  heart-suture '  we  have  first  to  note  the  fact 
that  it  has,  so  far  as  I  know,  only  once  been  done  in 
practice  (see  note  at  the  end  of  this  chapter) ;  next,  that 
only  the  most  strange  and  unlikely  set  of  conditions  could 
ever  bring  about  the  need  of  it.  It  is  quite  true  that 
Block  was  able  to  pass  sutures  into  the  hearts  of  rabbits, 
and  found  it  a  simple  procedure,  taking  only  three  or 
four  minutes ;  and  it  is  true  also  that  a  wound  of  the 
heart,  not  immediately  fatal,  with  haemorrhage  into  the 
pericardium,  may  give  the  surgeon  a  hope  of  saving  the 
patient's  life  by  withdrawal  of  the  effused  blood  by  aspi- 
ration or  even  by  incision. ^     It  is  not  impossible  that  the 


^  Thus,  in  1881,  Dr.  Roberts,  of  Philadelphia,  said  :  '  The  time 
may  possibly  come  when  wounds  of  the  heart  itself  will  be 
treated  by  pericardial  incision,  to  allow  extraction  of  clots, 
and  perhaps  to  suture  the  cardiac  muscle.'  Block's  experiments 
were  published  in  1882  ;  he  found  it  possible,  having  made  a 
penetrating  wound  into  either  ventricle  of  a  rabbit's  heart,  to 
take  hold  of  the  apex  of  the  heart,  and  draw  it  forward,  thus 
stopping  the  haemorrhage  and  steadying  the  heart  till  the  sutures 
were  put  in.  Dr.  Joseph  Bell  ("Trans.  Med.  Chir.  Soc.  Edin.," 
1894-95,  p.  36)  giving  an  account  of  a  fatal  case  of  a  small  wound 
of  the  heart,  with  distension  of  the  pericardium  with  blood,  says, 
'  The  youth  had  run  for  some  distance  before  he  died.  If  the 
surgeon  had  dilated  the  wound  and  turned  out  the  clot,  he  would 
not  have  required  to  suture  the  wound  in  the  heart ;  and  he 
might,  by  draining  under  antiseptic  precautions,  have  saved  the 
man's  life.'  A  similar  case,  where  this  was  done,  and  the 
patient  recovered,  is  given  in  the  chapter  on  '  Wounds  of  the 
Heart.' 


THE    "SURGERY    OF    THE    HEART."  373 

surgeon,  having  incised  the  pericardium  along  the  track 
of  the  external  wound,  might  see  a  wound  still  bleeding 
on  the  surface  of  the  heart,  and  might  pass  a  fine  suture 
through  it :  but  I  think  the  cases  given  in  the  chapter 
on  'Wounds  of  the  Heart'  are  on  the  whole  against  it. 
A  small  heart-wound  would  not  need  it ;  a  large  one 
would  not  give  the  chance  for  it.  Puncture  of  the  heart, 
on  the  other  hand,  has  been  done  a  great  many  times, 
either  by  accident  or  on  purpose ;  it  has  also  been 
made  the  subject  of  much  experimental  work.  Three 
arguments  are  put  forward  on  behalf  of  it :  first,  that 
simple  puncture  of  the  heart  with  a  needle  may  restore 
its  action  after  it  has  stopped ;  next,  that  the  withdrawal 
of  blood  from  its  cavities  may  save  life  in  cases  where 
it  is  overloaded  and  distended  with  blood  which  it 
cannot  of  itself  expel ;  last,  that  it  may  save  life  when 
air  has  reached  the  heart  through  a  wound  in  a  vein. 
Let  us  begin  with  the  experiments  on  animals,  and 
the  question  of  their  applicability  to  surgery,  and  then 
take  the  cases  where  the  heart  has  been  punctured  by 
mistake. 

Experiments  on  the  mammalian  heart,  to  show  how  its 
action  may  be  restored  or  relieved,  have  been  of  three 
kinds  :  stimulation  by  pressure,  stimulation  by  needling, 
and  aspiration  of  blood  from  one  of  its  cavities. 

It  is  certain  that  the  heart,  after  it  has  ceased  to 
beat,  may  be  restored  to  action  by  simple  handling  of 
it,  or  even,  as  Panum  has  noted,  by  blowing  on  it.  To 
those  who  make  experimental  study  of  the  heart,  it  is 
known  that  free  handling  of  it  does  not  in  any  way 
arrest  its  movements.  Block  found,  in  his  experiments 
on  suture  of  the  heart  in  rabbits,  that  he  could  start 
contraction,  after  it  had  stopped,  by  gently  squeezing 
the  heart ;   and  it  was  a  similar  observation   that   led 


374  SURGERY    OF    THE    CHEST. 

Watson  1  to  his  very  important  experiments  on  puncture 
and  aspiration.  These  facts  have  no  direct  bearing  on 
surgery  ;  but  at  least  they  show  that  if  the  surgeon  be 
ever  brought  face  to  face  with  the  necessity  of  touching 
the  human  heart,  he  may  do  this  without  fear  of  hindering 
its  action. 

Needle-puncture  of  the  heart,  with  or  without  aspiration 
of  blood  from  it,  has  been  very  carefully  studied,  with 
numerous  experiments,  by  Watson  and  Senn."  Watson's 
aim  was  to  find  a  means  of  averting  death  in  chloroform- 
syncope.  Senn  had  in  view  the  relief  of  the  heart  when 
air  has  passed  into  it  from  a  wounded  vein.  There  is 
no  room  in  this  book  for  more  than  a  short  notice  of 
their  work ;  but  this  at  least  may  give  soiiie  idea  of  it. 

Puncture  in  Chloroform-Syncope.      Watson's 
Experiments. 

Of  Watson's  sixty  experiments  on  dogs,  some  were 
simple  punctures  ;  others  were  punctures  with  a  hollow 
needle,  letting  out  a  few  drops,  or  a  few  ounces,  of  blood  ; 
but  on  some  occasions  no  blood  flowed  through  the 
needle.  In  none  of  the  experiments  was  blood  aspirated 
through  it.     In  some,  artificial  respiration  was  performed. 


'^  Having  killed  a  dog  with  chloroform,  he  exposed  the  heart, 
four  minutes  after  the  cessation  of  respiration,  and  found  it 
motionless  in  diastole ;  his  assistant,  at  this  moment,  seized  the 
heart  between  his  thumb  and  fingers,  and  it  began  at  once  to  act  ; 
the  contractions  soon  became  full  and  regular,  and  lasted  for 
some  minutes  ;  they  were  again  excited  by  the  same  method,  but 
soon  ceased.  Watson,  '  An  Experimental  Study  of  the  Effects  of 
Puncture  of  the  Heart  in  Cases  of  Chloroform  Narcosis,'  "  Trans. 
Amer.  Surg.  Ass.,"  1S87,  vol.  v.,  p.  275;  with  a  report  of  sixty 
experiments. 

=  Senn,  '  An  Experimental  and  Clinical  Study  of  Air-Embolism," 
"Trans.  Amer.  Surg.  Ass.,"  1885,  vol.  iii.,  p.  197;  with  a 
record  of  thirty -nine  experiments. 


THE    •'SURGERY    OF    THE    HEART."  375 

Forty  of  the  animals  had  suffered  some  severe  injury 
twenty  were  healthy.     The  anaesthetic  employed  to  arres 
the  heart's  action  was  always  chloroform  ;  in  fifty  cases  ^t 
was  given  rapidly  and  without  air  ;    in  ten  slowly,  with  a 
liberal  admixture  of  air.     In  forty-seven  out  of  the  sixty, 
the  moments  were  carefully  noted  at  which  the  respiration 
and  the  pulsation  stopped;    in   forty-four,    the    hear 
stopped  before  the  breathing;  in  one,  they  stopped  at 
the  same  moment;   in  two,  the  heart  went  on  for  half-a- 
minute  or  a  minute  after  the  breathing  had  stopped. 

The  results  obtained  by  puncture  were  very  striking. 
Out  of  sixty  experiments,  in  two,  and  in  two  only  did  the 
heart  fail  to  respond  :    in  one  of  these,  the  needle,  on  its 
way  to  the  heart,  got  stuck  in  the  lung;  m  the  othe 
puncture  was  not  made  till  four  minutes  after  the  heart 
had  ceased  to  beat.     In  twenty-two,  no  use  was  made  of 
artificial  respiration,  and  the  average  interval  of  time  be- 
tween cessation  of  the  heart's  action  and  introduction  of 
the  needle,  was  one  minute  and  twenty  seconds  :  in  all  ot 
these  the  heart  responded    to   the   stimulation.       ihe 
punctures  were  made  as  follows:    right  ventricle,   38^ 
left  ventricle,  6  ;  right  auricle,  6  ;  apex,  2  ;  and  m  5  the 
needle  passed  into  one  of  the  ven^  cavee.      Ten  out  ot 
the  sixty  animals,  though  their  hearts  had  ceased  to  beat, 
were  yet  restored  to  life  by  the  puncture,  and  completely 
recovered  ;   one  of  them,  indeed,  after  two  experiments, 
recovered  twice.     The  punctures  in  the  ten  cases  that 
recovered,  were  all  made  into  the  right  ventricle,  except 
one  into  the  right  auricle. 

To  emphasize  these  ten  recoveries,  we  may  note  that 
forty  of  the  dogs  had  already  received  various  injuries 
and  were  to  be  put  to  death  on  this  account ;  and  six  ot 
the  ten  recoveries  occurred  among  the  twenty  that  were 
healthy     The  dogs  were  still  alive  when  Dr.  Watson  pub- 


376  SURGERY    OF    THE    CHEST. 

lished  his  report.  In  none  of  the  sixty  was  the  puncture 
made  less  than  a  minute  after  the  heart's  action  had 
ceased.  The  cases  where  blood  was  let  out  did  better 
than  those  where  simple  puncture  was  performed.  In  no 
less  than  thirty-two,  there  was  an  interval  of  time  between 
the  puncture  and  the  return  of  the  heart's  action :  it 
ranged  from  a  few  seconds  to  three  minutes.  Puncture 
of  the  auricle  was,  in  several  cases,  followed  by  consider- 
able haemorrhage  into  the  pericardium  :  this  did  not 
happen  in  any  of  the  thirty-eight  experiments  where  the 
ventricle  was  punctured. 

We  must  admit  that  no  results  of  this  kind  have  been 
obtained  in  surgery.  Dr.  Kinloch  tried  it  in  a  case 
of  chloroform-syncope,  without  result.  Dr.  Dana  ("  New 
York  Med.  Rec,"  Feb.  1883)  states  that  he  has  often 
punctured  the  heart  in  animals,  and  by  so  doing  has 
sometimes  stimulated  and  never  checked  it ;  but  he  got 
no  results  in  two  cases  where  he  did  it  in  practice.  Dr. 
Corwin  {Ibid.,  March  1883)  admits  that  he  never  saw 
any  good  come  of  this  method  of  restoring  life,  though 
he  has  practised  it,  or  seen  it  practised,  many  times. 
But  these  were  not  cases  of  chloroform-syncope. 

It  is  not  wholly  free  from  risk.  Fischer,  of  Breslau 
("  Deutsch.  Ztschr.  f.  Chir.,"  1875)  practised  it  in  a  case 
of  chloroform-syncope  without  success,  and  the  post 
mortem  examination  showed  the  coronary  artery  punctured 
in  two  places,  and  the  pericardium  full  of  blood.  It  is 
said  to  have  been  the  cause  of  death  in  more  than  one 
case;  and  the  silence  of  recent  years  shows  clearly  that 
there  have  been  no  signal  successes  with  it. 

Still,  we  cannot  simply  set  aside  Dr.  Watson's  facts. 
They  are  not  concerned  with  anything  but  chloroform- 
syncope,  and  the  results  he  obtained  apply  to  this  con- 
dition   alone.       In    a    case   of  apparent   death   under 


THE    "SURGERY    OF    THE    HEART."  377 

chloroform,  where  it  was  certain  that  the  heart  had 
stopped,  it  would  be  at  all  events  better  than  nothing  to 
take  the  last  hope  offered  by  puncture.  A  fine  aspirating 
needle,  without  the  aspirator,  should  be  used  ;  or  even, 
if  this  were  not  to  hand,  a  simple  long  needle.  It  should 
be  put  in  through  the  fourth  space,  an  inch  and  a  half  or 
two  inches  to  the  left  of  the  middle  line. 

Aspiration  in  Air-Embolism.     Senn's  Experiments. 

Senn's  work  in  1885,  on  the  entry  of  air  through  the 
veins  into  the  heart,  contains  not  only  a  valuable  col- 
lection of  cases,  but  also  an  account  of  thirty-nine 
experiments  on  various  animals.  In  ten  of  these,  having 
driven  air  along  one  of  the  jugular  veins  into  the  heart, 
he  then  withdrew  the  air  and  blood,  by  means  of  an 
aspirator,  from  the  right  ventricle.  In  seven,  having 
driven  air  into  the  heart,  he  withdrew  it  by  means  of 
a  catheter  passed  down  the  wounded  vein  into  the  right 
auricle.  In  two,  he  drove  the  air  straight  into  the  right 
ventricle  through  a  needle,  and  then  withdrew  it.  Three 
out  of  the  ten  animals,  and  three  out  of  the  seven  re- 
covered, though  their  condition  had  appeared  past  hope 
of  relief  He  used  an  aspirating  needle  2  mm.  in 
diameter,  carefully  sterilized ;  he  made  his  vacuum  as 
soon  as  the  needle  was  through  the  skin,  so  that  he 
might  find  the  cavity  of  the  ventricle  without  going  too 
far  into  it,  and  directed  the  needle  upward  so  as  to  make 
a  more  valvular  opening  into  the  cavity,  and  to  avoid 
injuring  the  lining  membrane  of  its  opposite  wall.  While 
we  must  admire  the  skill  and  thoroughness  of  Dr.  Senn's 
work,  we  must  also  note  that  it  was  severely  criticized 
when  he  brought  it  before  the  American  Surgical  Associ- 
ation ;  and  indeed  there  is  a  wide  difference  between  the 
condition  produced  in  an  animal  by  inflating  its  heart 


378  SURGERY    OF    THE    CHEST. 

with  air,  and  the  entry  of  air  into  a  vein  during  an 
operation.  To  the  question,  '  What  symptoms,  after  air 
has  entered  a  vein,  indicate  the  need  of  puncture  and 
aspiration  of  the  right  ventricle '  ?  he  rephes  that  im- 
mediate collapse,  with  complete  or  almost  complete 
arrest  of  the  heart's  action,  shows  that  the  heart  has  been 
suddenly  distended  with  air  and  paralyzed  ;  subsequent 
tumultuous,  rapid,  or  intermittent  action,  with  churning 
sounds  heard  over  the  cardiac  area,  rapid  breathing,  pallor, 
and  blueness  of  the  lips,  shows  that  the  air  has  already 
begun  to  invade  the  pulmonary  artery ;  and  in  either  of 
these  conditions  the  aspirator  should  be  used.  But  the 
records  of  this  disaster  show  so  many  recoveries  without 
any  treatment  of  this  kind,  and  so  many  cases  of 
immediate  death  where  there  would  be  no  chance  of 
trying  it,  that  we  can  hardly  expect  ever  to  find  a  use  for 
it.  Doubtless,  if  one  should  hear  these  churning  sounds, 
and  see  the  whole  picture  of  the  air-distended  heart 
as  Senn  has  drawn  it,  he  would  be  justified  in  attempting 
this  method  ;  but  it  is  likely  that  Senn's  work  will  remain 
rather  a  monument  of  experimental  science  than  a  con- 
tribution to  the  necessities  of  surgery. 

Aspiration  in  Simple  Distension. 
Westbrook's  Case. 

A  third  novelty  of  surgery,  also  from  the  New  World, 
was  proposed  in  1882  and  18S3,  that  one  should  puncture 
the  heart  for  simple  distension,  such  as  occurs  in  acute 
pneumonia  with  impeded  circulation  through  the  lungs  ; 
that  one  should,  in  short,  bleed  the  patient  a  few  drachms 
from  the  heart,  instead  of  a  few  ounces  from  the  arm. 
In  1883,  the  following  extraordinary  sentence  was  written 
on  behalf  of  this  method  :  'Further  experimentation  in 
heart-puncture  for  the  relief  of  cardiac   distension  and 


THE    "SURGERY    OF    THE    HEART."  379 

pulmonary  engorgement  is  requisite,  but  it  is  probable 
that  it  will  soon  become  a  well-recognized  surgical 
procedure  in  selected  cases. 'i  The  case  where  this 
method  was  adopted  occurred  in  November,  18S2-:  it 
was  that  of  a  man,  aged  50,  with  very  severe  pneumonia 
of  the  right  lung.  '  The  struggle  was  evidently  hopeless  ; 
it  was  plain  that  there  was  no  longer  any  chance  of 
recovery.'  It  was  decided  to  aspirate  the  right  auricle  : 
a  very  fine  needle  was  passed  through  the  third  right 
intercostal  space,  close  to  the  sternum,  to  a  depth  of  two 
inches  ;  but  only  a  few  drops  of  blood  came  into  the 
bottle.  It  was  now  pushed  a  little  further,  and  touched 
hard  calcareous  matter,  and  had  evidently  punctured  the 
aorta.  It  was  drawn  a  little  way  back,  and  about  a 
drachm  of  blood  was  got  from  the  auricle.  Half-an-hour 
later,  a  large  needle  was  used,  and  about  three  ounces  of 
blood  was  withdrawn  without  trouble.  The  patient  was 
relieved,  but  died  the  next  morning.  J^os^  mortem,  three 
or  four  ounces  of  thin  blood-stained  fluid  in  the  peri- 
cardium. 

I  can  see  no  reason  why  this  method  should  ever 
be  employed  in  these  cases,  nor  what  advantage  could  be 
gained  from  it  that  would  not  more  safely  be  obtained  by 
venesection. 

Accidental  Puncture  of  the  Heart. 

We  have  now  gone  through  several  proposals  for 
suture,  aspiration,  and  puncture  of  the  heart,  and  have 
got  small  encouragement  to  adopt  them.     We  come  next 


'  Dr.  J.  B.  Roberts,  a  paper  read  before  the  College  of  Physi- 
cians of  Philadelphia,  Jan.  3rd,  1883. 

^Dr.  Westbrook.  On  'Abstraction  of  Blood  from  the  Right 
Heart.'     "  New  York  Medical  Record,"  1S82,  vol.  ii.,  p.  705. 


s8o  SURGERY    OF    THE    CHEST. 

to  a  curious  group  of  cases/  where  the  heart  itself  has 
been  punctured,  unintentionally,  during  some  operation 
on  the  pleura  or  the  pericardium. 

1.  In  1872,  m  the  case  of  a  child  five  years  old,  with  peri- 
cardial effusion,  the  surgeon,  having  withdrawn  the  fluid, 
accidentally  punctured  the  right  ventricle,  and  withdrew  from 
it  about  6J  ounces  of  pure  venous  blood.  This  was  followed 
by  pallor,  sweating,  and  failure  of  the  pulse  ;  but  the  child 
recovered.  He  died  five  months  later  from  long-standing 
dilatation  and  valvular  disease  of  the  heart. 

2.  In  1873,  a  girl,  aged  11  years,  having  inflammation  of 
the  heart  and  pericardium,  with  hsemorrhagic  effusion,  was 
treated  with  puncture  of  the  pericardium  on  eight  occasions 
during  thirty-four  days.  On  two  of  them,  the  heart  was 
slightly  wounded,  but  no  bad  result  was  observed.  She 
died  three  days  after  the  last  operation. 

3.  In  1875,  a  woman,  aged  27,  with  signs  of  enlarged  and 
diseased  heart,  and  of  pericardial  effusion,  after  rheumatic 
fever,  was  treated  with  puncture  with  a  fine  trochar  and 
cannula.  '  We  knew  that  we  had  a  very  large  heart  to  deal 
with  ;  nevertheless,  the  rapid  increase  in  the  dull  area  after 
admission  to  Hospital,  and  the  bulging  of  the  chest-wall,  to- 
gether with  apparently  considerable  mufiling  of  the  sound  of 
the  heart,  seemed  almost  certainly  to  indicate  fluid  in  the 
pericardium.'  The  puncture  was  made  in  the  fourth  space, 
about  half-an-inch  to  the  left  of  the  sternum  ;  a  gush  of  dark 
blood  came  through  the  cannula,  and  it  was  observed  to 
move  with  the  heart.  It  was  quickly  withdrawn :  only 
about  a  drachm  of  blood  was  removed.  '  The  patient,  who 
before  the  operation  was  almost  moribund,  rallied  after  it, 
expressed  herself  as  being  relieved  by  it,  and  lived  for  nearly 
four  weeks,  the  distension  of  the  heart  having  gradually 
diminished.' 

4.  In  1877,  a  woman,  suffering  from  dilatation  and  mitral 
disease  of  the  heart,  with  orthopnoea,  pulmonary  congestion, 
and  general  anasarca,  came  under  the  care  of  two  homoeo- 
pathic doctors,  who  diagnosed  pericarditis  with  effusion. 
'  They  attempted  aspiration,  with  the  result  that  the  needle 


'  For  references,  see  "  Trans.  Med.  Chir.  Soc.  Edin.,"  1894-95, 
vol.  xiv.,  p.  24;  "Clin.  Soc.  Trans.,"  1S75,  vol.  viii.,  p.  169.  In 
Dr.  West's  tables,  there  are  one  or  two  other  cases  where  the 
heart  was  wounded  in  paracentesis  of  the  pericardium. 


THE    "SURGERY    OF    THE    HEART."  381 

penetrated  the  ventricle,  and  ten  to  fifteen  ounces  of  blood 
were  withdrawn  ;  the  urgent  symptoms  were  for  a  time 
relieved.  They  did  not  recognize  that  they  had  penetrated 
the  heart,  and  made  a  second  attempt,  after  some  days' 
interval  :  but  the  patient  died  in  a  short  time.  At  the  posi 
tnorfem,  the  marks  of  the  punctures  were  distinctly  visible.' 

5.  In  1883,  a  man,  aged  40,  was  admitted  to  Hospital 
with  acute  nephritis  and  congestion  of  the  lungs.  His  chest 
was  much  deformed  by  a  lateral  curvature  of  the  spine  ;  the 
apex-beat  was  an  inch  or  more  above  the  left  nipple,  and 
there  was  thought  to  be  considerable  enlargement  of  the 
heart.  '  The  question  of  hydro-pericardium  being  raised, 
the  needle  of  a  veterinary  hypodermic  syringe  was  introduced 
at  a  point  where  there  was  dulness  on  percussion,  and  but 
little  or  no  movement  apparent  on  palpation.'  The  barrel  of 
the  syringe  was  immediately  filled  with  dark  venous  blood, 
and  the  needle  was  felt  to  move  slightly  with  the  heart.  No 
change,  good  or  bad,  followed  this  occurrence.  The  patient 
died  next  day.  The  posi  mortem  examination  showed  a 
small  ecchymosed  spot  about  an  inch  above  the  apex  ;  no 
haemorrhage  into  the  pericardium. 

6.  In  1894,  Dr.  Sloan  reported  a  case  of  very  great 
interest.  A  girl,  aged  19,  during  a  severe  attack  of  rheumatic 
fever,  complained  of  oppression  and  prsecordial  pain,  and 
was  found  to  have  a  well-marked  friction  sound  over  the 
heart.  A  few  days  later,  this  disappeared  ;  then  it  returned, 
together  with  a  well-marked  systolic  murmur,  and  the  patient's 
general  condition  became  slowly  hopeless  :  she  suffered 
excruciating  pain,  sickness,  a  hacking  cough,  pulse  120-140, 
feeble  and  dicrotic,  respiration  30-50.  'The  livid,  anxious 
countenance,  the  pallor  of  the  lips,  the  working  of  the  alae 
nasi,  the  dilatation  of  the  veins  of  the  neck,  and  increased 
general  restlessness,  all  indicated  rapid  effusion  into  the 
pericardium.'  There  was  marked  increase  of  cardiac  dulness 
— fully  an  inch  to  right  of  sternum,  and  up  to  second  space 
— the  friction-sound  was  still  heard,  the  heart-sounds  were 
feeble.  On  June  13th,  1894,  she  suddenly  collapsed,  and  the 
heart  and  breathing  both  stopped.  '  I  seized  the  aspirator, 
and  plunged  the  needle  into  the  fourth  space,  about  half-an- 
inch  to  the  left  of  the  sternum.  To  my  astonishment,  from 
eight  to  ten  ounces  of  pure  blood  flowed  rapidly  into  the 
bottle  and  then  suddenly  stopped.  As  I  was  slowly  with- 
drawing the  cannula,  to  my  surprise  the  heart  made  first  a 
feeble  irregular  movement,  then  gave  a  sudden  strenuous 
jump,  and  finally,  like  a  pendulum  regaining  its  swing  or  a 


332  SURGERY    OF    THE    CHEST. 

runner  his  stride,  it  started  to  beat  again  in  the  race  for  hfe.' 
She  slowly  recovered,  and  was  restored  to  health.' 

7.  A  patient,  suffering  from  ulcerative  endocarditis  and 
dilated  heart,  presented  signs  also  of  pericardial  effusion  ; 
puncture  was  made  with  an  ordinary  exploring  syringe,  and 
the  surgeon  found  that  he  had  punctured  the  heart.  Blood 
was  drawn  off  with  the  syringe  ;  the  needle  was  at  once 
withdrawn  ;  the  patient  died  in  half-an-hour.  The  />osi 
jHor/em  examination  showed  the  pericardium  distended  with 
blood,  and  a  small  wound  in  the  right  ventricle. 

These  cases,  though  they  are  full  of  interest,  do  not 
give  us  much  guidance.  We  hear  of  the  successes,  but 
not  of  the  disasters.  A  non-penetrating  puncture  can  do 
nothing  but  harm ;  a  penetrating  puncture,  with  abstrac- 
tion of  blood  from  the  right  ventricle  has  been  known 
to  do  good  to  a  dilated  and  failing  heart ;  but  we  do  not 
hear  of  the  cases  where  it  did  harm ;  and  even  in  those 
one  or  two  cases  where  it  did  good,  we  must  still  ask 
wdiether  venesection  might  not  have  had  the  same  result. 

We  have  now  gone  through  the  various  methods  of 
suture,  aspiration,  and  puncture  of  the  heart,  suggested 
by  experiment,  practised  of  set  purpose,  or  inflicted  by 
chance.  The  quest  has  not  been  very  successful ;  but 
we  have,  I  think,  found  reason  to  beheve  that  uuncture 
of  the  right  ventricle  may  be  useful  in  desperate  cases 
of  chloroform-syncope :  and  that  suture  of  a  wound  of 
the  heart  is  at  least  not  impossible. 

Note. — A  wound  of  the  heart  has  lately  been  treated 
by  free  exposure  and  suture  by  Cappelen  :  the  patient,  a 
man  24  years  old,  was  stabbed  in  the  fourth  left  space 
in  the  axillary  line.  He  went  home  alone,  and  about  an 
hour  later  was  found  lying  in  a  pool  of  blood.     He  was 

'  There  is  no  room  here  for  the  details  of  this  case.  The  reader 
should  consult  Dr.  Sloan's  vivid  account  of  it,  in  the  "Transac- 
tions of  the  Medico-Chirurgical  Society  of  Edinburgh,"  1894-5. 


THE    •'SURGERY    OF    THE    HEART."  383 

brought  to  Hospital  unconscious  :  external  haemorrhage 
had  stopped,  pulse  could  not  be  felt,  but  faint  heart- 
sounds  were  heard  to  right  of  sternum. :  left  side  of  chest 
did  not  move  in  respiration.  After  a  stimulant  injection 
of  camphor,  chloroform  was  given,  the  wound  was 
enlarged,  the  fourth  rib  was  resected,  and  the  pleura 
was  found  filled  with  blood,  part  fluid,  part  coagulated, 
compressing  the  lung :  it  was  estimated  at  2^  pints. 
After  its  removal  the  lung  expanded,  and  was  found  not 
wounded.  A  piece  of  the  third  rib  was  now  resected, 
and  a  wound  of  the  pericardium  was  seen  bleeding  freely. 
This  was  enlarged,  the  sac  was  found  filled  with  clots, 
and  a  wound  nearly  an  inch  long  was  found  on  the  left 
ventricle,  causing  the  bleeding.  It  was  sutured,  and  an 
artery  was  tied :  after  this  the  bleeding  stopped.  The 
needle  was  brought  halfway  through  during  a  contraction 
and  then  dropped ;  and  when  the  heart  dilated  after  a 
second  contraction,  the  point  of  the  needle  was  grasped 
and  it  was  drawn  the  rest  of  the  way.  The  suturing  was 
made  very  difficult  by  the  rhythmic  movements  of  the 
lung,  which  covered  the  whole  field  of  operation,  and 
by  the  movements  of  the  heart,  but  these  were  perfectly 
regular  and  quiet  all  the  time.  The  clots  in  the  pericar- 
dium were  removed,  so  far  as  possible  :  the  pulse  after 
operation  was  very  quick  and  feeble,  but  improved  after 
a  hypodermic  injection  of  saline  solution.  The  patient 
sank  and  died  two-and-a-half  days  later.  The  post 
mortem  examination  showed  that  a  large  branch  of  the 
coronary  artery  had  been  wounded :  the  wound  had 
begun  to  heal,  but  there  was  evidence  of  pericarditis. 
The  knife  had  passed  through  the  fold  of  the  pleura 
without  wounding  the  lung. 

Cappelen  published  this  case  in  March  of  this  year. 
See  Epitome,  "Brit.  Med.  Journ.,"  May  23rd,  1896. 


3S4 


CHAPTER  XXV. 

PERICARDIAL    EFFUSIONS. 

We  need  not  go  outside  this  country  for  the  literature  of 
the  surgery  of  pericardial  effusions.  There  is  such  a 
wealth  of  it  in  our  own  language,  that  my  difficulty  is  to 
know  how  best  I  may  present  some  small  part  of  it  in 
this  chapter.  The  introduction  of  the  operation  into 
England,  and  the  careful  study  of  the  exact  indications 
for  it,  and  of  the  best  way  of  doing  it,  have  been  the 
work  of  the  physicians,  not  the  surgeons  :  it  is  one  of 
the  greatest  triumphs  of  surgery,  but  the  surgeons  did 
not  win  it  for  themselves. 

I  will  endeavour,  from  the  chief  medical  writings  about 
it,i  to  set  down  those  rules,  methods  and  difficulties  that 
we  must  bear  in  mind  in  the  surgical  treatment  of  these 
cases.  We  have  to  remember  that  the  need  for  operation 
may  arise  suddenly,  and  that  we  should  be  as  ready  to 
perform  it  as  we  are  to  do  tracheotomy. 

History. 

The  history  of  paracentesis  pericardii  is  a  good  com- 
ment on  John  Hunter's  advice — "  Don't  think ;  try." 
The  operation  was  advocated  by  Riolan  (1649)  ^.nd 
Senac  (1749),  and  many  other  writers,  long  before  it  was 

'Ogle,  "Clin.  Soc.  Trans.,"  1873,  vi.,  131  ;  Steavenson,  "St. 
Bart,  Hosp.  Reports,"  1881,  xvii.,  217  ;  West,  "Med.  Chir.  Soc. 
Trans.,"  1883,  Ixvi.,  235  ;  Sir  Grainger  Stewart,  "  Med.  Chir.  Soc. 
Edin.  Trans.,"  1884-85,  iv.,  53;  Ewart,  "Brit.  Med.  Journ.,"Mar. 
21,  1S96.  References  to  isolated  cases  are  too  numerous  to  be 
put  liere. 


PERICARDIAL    EFFUSIONS.  385 

first  performed  by  Romero  of  Barcelona  (18 19)  in  three 
cases,  two  of  whom  recovered.  In  Germany,  Schuh 
(1839)  was  the  first  who  did  it;  in  Russia,  Karawajew 
(^839);  in  France,  the  honour  is  due  to  Trousseau  of 
establishing  it  past  criticism  ;  in  England,  Sibson  (1854) 
and  Clifford  Allbutt  (1866-70)  were  its  first  advocates  ; 
and  in  1873,  Dr.  John  Ogle  was  able  to  collect  records 
of  seven  cases  where  it  had  been  performed  in  England 
and  Scotland.  The  operation  was  now  generally  recog- 
nized :  Hindenlang  in  1879,  Roberts  of  Philadelphia,  in 
1880,  West  in  1883,  and  Sir  Grainger  Stewart  in  1885, 
drew  attention  to  it  in  Germany,  America,  England,  and 
Scotland  ;  and  we  have  a  great  store  of  long  treatises  on 
it,  with  a  multitude  of  recorded  separate  cases. 

The  advance  to  free  incision  and  drainage,  for  the  cure 
of  purulent  pericardial  effusion,  was  made  by  Rosenstein 
of  Leyden,  in  1881,  and  in  this  country  by  West,  in  1882. 

A  year  before  Romero's  operations,  Skielderup  punc- 
tured the  pericardium  by  means  of  a  trephine-hole  in  the 
sternum  ;  Malle  (187 1)  did  the  same  thing,  but  there  is 
nothing  to  be  said  in  favour  of  this  way  of  doing  it. 
Both  Romero  and  Trousseau  made  an  incision  down  to 
the  pericardium,  exposed  it,  felt  it,  and  not  till  then 
punctured  it,  or  picked  it  up  with  the  forceps  and  incised 
it.  This  has  been  called  a  coarse  way  of  operating,  but 
it  seems  to  me  to  have  a  good  deal  in  its  favour.  In  the 
first  place,  the  needle  is  less  likely  to  go  too  far  and 
wound  the  heart ^  :  in  the  next,  the  surgeon  might  avoid 

' '  If  there  be  not  a  large  amount  of  fluid,  and  if  the  cannula 
and  trochar  be  passed  into  the  pericardium  with  a  jump,  or  the 
patient  make  a  sudden  movement,  a  vein  on  the  surface  of  the 
heart  may  be  wounded.  It  is  best  to  make  a  small  incision 
through  the  skin,  and  to  pass  the  trochar  gradually  into  the 
pericardium,  without  the  jump  that  is  unavoidable  when  it  has 
to  be  thrust  through  the  skin.'  Mr.  Sheild,  "Med.  Soc.  Trans." 
1895,  xviii.,  188. 

25 


386 


SURGERY    OF    THE    CHEST. 


the  common  danger  of  puncturing  a  dilated  heart  in 
mistake  for  a  pericardial  effusion.  In  some  cases,  an 
'  exploratory  incision  '  might  be  safer  than  an  '  explora- 
tory puncture.'  We  should  only  be  applying  to  the 
pericardium  a  rule  which  is  followed  in  general  surgery. 


Outlines  of  the  total  and  of  the  absolute  dulness  in  pericardial  effusion. 
A,  position  of  apex  (fifth  space).  Arrows  show  dulness  extending  below  and 
beyond  it.  T,  patch  of  tubular  breathing  below  right  breast.  F,  upper  edge 
of  first  rib,  made  accessible  to  touch  by  lifting  of  the  clavicle.  From  Ewart, 
"Diagnosis  of  Pericardial  Effusion." — '  Brit.  Med.  Jour.,"  Mar.  21,  1896. 


Diagnosis. 

As  one  reads  the  literature  of  this  subject,  one  finds 
innumerable  references  to  the  difficulty  of  diagnosis 
between  extreme  dilatation  of  the  heart  and  pericardial 


PERICARDIAL    EFFUSIONS.  387 

effusion,  and  many  cases  where  mistakes  have  been 
made,  even  by  Trousseau  himself  and  others  of  Hke 
standing.  Perhaps,  in  such  cases,  a  carefully-planned 
exploratory  incision  would  be  safer  than  puncture  ;  at 
all  events,  it  may  be  useful  if  I  put  here  the  signs  of 
pericardial  effusion  given  by  Dr.  Ewart  in  the  very 
valuable  paper  that  he  has  just  published.^  They  apply 
only  to  such  large  effusions  as  are  likely  to  need  surgery. 
He  has  kindly  let  me  make  use  of  one  of  his  diagrams 
(page  386). 

First  Sign.  Considerable  Exte7ision  of  the  Lateral 
Boicndaries  of  the  Total  Area  of  Dulness. — The  border  of 
the  lungs  does  not  coincide  with  the  lateral  boundaries  of  the 
distended  sac,  but  overlaps  it.  It  is  the  superficial  resonance 
of  their  fringes,  and  the  puerile  vesicular  murmur  arising 
from  them,  which  are  apt  to  mislead  us.  A  careful  per- 
cussion will  guard  us  against  this  danger,  and  will  enable  us 
to  delineate  a  complete  outline  of  the  sac. 

Second  Sign.  Great  Extension  of  the  Absolute  Dubiess: 
the  Steriiwn  Absolutely  Dull. — A  much  enlarged  heart, 
aneurysm,  abscess,  or  mediastinal  new  growth,  would  like- 
wise completely  deprive  the  sternum  of  its  normal  resonance ; 
this  change,  therefore,  by  itself  is  not  absolutely  diagnostic, 
but  is  of  great  importance  in  conjunction  with  other 
changes. 

Third  Sign.  Depression  of  the  Liver. — Any  cardiac 
enlargement,  and  any  considerable  pulmonary  distension, 
will  produce  more  or  less  displacement  downward  of  the 
hepatic  line  of  absolute  dulness  ;  but  in  no  other  condition, 
except  pneumothorax  and  intrathoracic  sarcoma,  is  the 
depression  of  the  liver  so  marked,  at  least  in  the  middle  line, 
as  in  large  pericardial  effusions. 

Fourth  Sign. — Dulness  between  the  Fifth  and  Sixth 
Right  Costal  Cartilages j  Rotclis  Sign. — This  is  the  result  of 
the  accumulation  of  fluid  within  the  right  corner  of  the  sac, 
a  very  valuable  sign,  but  not  absolutely  diagnostic.  A  case 
has  been  recorded  of  tricuspid  stenosis,  with  enormous  dila- 

'  Ewart,  "  Practical  Aids  in  the  Diagnosis  of  Pericardial 
Effusion,  in  connection  with  the  question  as  to  Surgical  Treat- 
ment."    "  Brit.  Med.  Journ.,"  Mar.  21,  i8g6. 


388  SURGERY    OF    THE    CHEST. 

tation  of  the  right  auricle  :  such  a  condition  might  also  give 
this  dulness. 

Fifth  Sign.  TAe  Lower  Aiigle  of  the  Pericardial  Dul- 
ness projects  tozvard  the  Ri^ht. — Instead  of  the  normal 
convexity  of  the  edge  of  the  right  auricle,  downward  and 
inward  toward  the  ensiform  cartilage,  the  outline  of  a  peri- 
cardial effusion  is  that  of  a  bag  of  fluid  spreading  out  at  its 
base  ;  the  lowermost  level  is  also  that  of  the  greatest  width 
of  dulness  from  side  to  side,  and  the  lowermost  angle  projects 
outward. 

Sixth  Sign.  The  Left  Lower  Angle  of  Dulness j  the 
Relatio7i  of  the  Apex-Beat  to  this  Angle. — Here  again  the 
pyramidal  shape  of  the  dulness  gives  a  prominent  angle 
toward  the  left,  instead  of  the  somewhat  rounded-ofif  outline 
which  is  normal.  But  this  is  not  an  absolute  guide,  since 
any  condition  that  prevents  the  natural  overlapping  of  the 
lung  over  the  heart  may  give  a  like  result.  On  the  other 
hand,  the  relation  of  the  apex  to  the  left  angle  of  dulness  is 
of  great  diagnostic  value.  In  all  cases  of  enlargement  of 
the  heart,  or  displacement  of  it  to  the  left,  the  apex-beat  is  at 
the  extreme  left  limit  of  the  dulness,  and  at  its  lowest  level. 
This  is  not  the  case  in  pericardial  effusion.  The  apex  cannot 
be  felt,  in  cases  where  there  is  much  effusion,  but  it  will  be 
heard  beating  at  a  point  somewhat  inside  and  above  the 
boundaries  of  dulness.' 

Seventh  Sign.  The  Upper  Edge  of  the  First  Rib  can  be 
felt  on  palpation,  as  far  as  its  Sternal  Attachment. — This 
points  to  a  raising  of  the  clavicle,  not  only  in  its  outer  but 
also  in  its  inner  portion,  and  to  a  relaxation  of  the  ligament 
between  it  and  the  first  rib.  I  have  rarely  seen  this  sign  in 
the  absence  of  pericardial  effusion,  except  in  some  cases  of 
considerable  enlargement  of  the  heart. 

Eighth  Sign.     The  Posterior  Pericardial  Patch  of  Diil- 

'  '  I  cannot  avoid  warning  you  against  a  remarkable  miscon- 
ception, hitherto  perpetuated  by  the  text-books,  as  to  the  alleged 
elevation  of  the  apex  within  the  effusion  even  as  high  as  the 
third  interspace.  That  an  impulse  can  usually  be  felt  there  is 
not  surprising,  but  this  impulse  is  not  of  the  apex  of  the  heart, 
but  rather  of  its  base.  If  we  drop  a  heart,  or  a  thin  membranous 
bag  with  some  blood  in  it,  into  fluid  of  the  usual  density  (loiS) 
of  a  pericardial  effusion,  it  will  sink  to  the  bottom.  The  heart, 
therefore,  even  in  diastole,  cannot  float  in  serum.  Again,  the 
heart  is  tethered  to  the  bottom  of  the  pericardium  by  the  attach- 
ment of  the  vena  cava  inferior.  I  have  in  some  cases  detected  a 
lowering  of  the  heart's  apex  in  pericardial  effusion.' 


PERICARDIAL    EFFUSIONS.  389 

ness. — A  patch  of  marked  dulness  over  the  base  of  the  left 
lung  behind,  extending  outward  from  the  spine,  usually  not 
quite  so  far  as  the  line  of  the  angle  of  the  scapula,  and 
ceasing  abruptly  with  a  \  ertical  outer  boundary.  Upward,  it 
does  not  usually  extend  higher  than  the  ninth  or  tenth  rib, 
and  here  again  its  boundary  is  abrupt.  Its  shape,  therefore, 
is  square,  quite  unlike  that  of  any  dulness  arising  from 
pleuritic  effusion.  The  breath-sounds  over  it  are  absent,  and 
the  voice-sounds  feeble.  In  a  case  of  very  large  pericardial 
effusion,  this  patch  of  dulness  may  extend  a  little  way  to 
the  right  side. 

Ninth  Sign.  TuIhiIm-  Breathing  below  the  Right  Breast. 
This  sign  is  not  constant,  but  should  be  looked  for  in  severe 
cases  ;  it  is  usually  heard  about  the  nipple  line,  and  some- 
times in  expiration  only. 

Tenth  Sign. — The  Posterior  Pericardial  Patch  of  Tubu- 
lar Breathing  and  ^^^/i/zf?;?)/.— Immediately  below,  or  a 
little  to  the  left,  of  the  lower  angle  of  the  scapula,  there  is  a 
patch  of  well-marked  tubular  breathing  and  asgophony, 
about  2  inches  in  diameter.  This,  though  not  so  important 
as  the  eighth  sign,  is  very  commonly,  if  not  always,  present 
in  cases  of  considerable  pericardial  effusion.  It  also  occurs  in 
pleural  effusions. 

Eleventh  Sign.  The  Secondary  Pleural  EJ/usions. — 
These,  probably  due  to  pressure,  are  among  the  most 
common  complications  of  pericardial  effusion  in  its  later 
stages.  The  pleural  effusion  frequently  begins  on  the  right 
side  ;  but  it  often,  at  last,  occurs  on  both. 

Twelfth  Sign.  The  Pulse  in  Pericardial  Effusion. — 
The  pulstts  paradoxus,  pulsus  cum  inspiratione  interviittens, 
is  an  important  sign,  but  is  characteristic  of  mediastinal 
rather  than  of  pericardial  disease,  and  cannot  be  regarded 
as  diagnostic  of  the  latter.  I  have  frequently  observed  in 
pericardial  effusion  an  opposite  condition  of  the  pulse  ;  a 
large  slapping  beat,  with  very  sudden  impact  and  quick 
collapse  of  the  wave ;  in  fact,  it  is  Corrigan's  pulse,  almost  or 
a  typical  kind,  though  never  so  extreme  as  in  well-marked 
aortic  regurgitation. 

Such  are  the  twelve  signs  of  a  large  pericardial  effusion 
given  by  Dr.  Ewart,  in  addition  to  those  that  are  more 
familiar.  He  lays  special  stress  on  the  fifth,  sixth,  and 
ninth  ;  and  all  of  them  refer  only  to  such  large  effusions 
as  are  likely  to  need  surgical  treatment. 


390  SURGERY    OF    THE    CHEST. 

Indications  for  Operations. 

But  there  is  no  clear  rule,  how  large  the  effusion  must 
be  before  the  surgeon  shall  interA^ene.  Dr.  Percy  Kidd' 
has  recorded  the  case  of  a  man,  aged  40,  with  pericardial 
effusion  due  to  rheumatism,  whose  condition  was  such 
that  for  several  days  he  thought  to  recommend  paracen- 
tesis ;  the  day  he  made  up  his  mind  to  do  so,  the  patient 
began  to  amend,  and  recovered  without  operation.  In 
Dr.  Ogle's  case,  a  man  aged  34,  the  area  of  cardiac 
dulness  reached  the  enormous  size  of  6  inches  by  7. 
'  The  agony  and  distress  of  breathing,  and  the  sleepless- 
ness, were  so  great  that  the  indications  for  operation 
were  clear,  and  we  were  on  the  point  of  tapping  the 
pericardium.  Still,  bearing  in  mind  the  possibility  of 
untoward  circumstances  resulting  from  the  operation,  I 
hesitated  in  having  recourse  to  it ;  and  the  event  proved 
that  the  delay  was  justifiable.  Had  there  been  positive 
and  manifest  interference  with  the  oxygenation  of  the 
blood,  or  had  anasarca  been  occasioned,  I  should  un- 
doubtedly have  had  the  operation  performed.' - 

From  a  surgical  point  of  view,  it  is  hard  to  see  what 
case  can  ever  need  paracentesis  if  this  did  not.  The 
exact  amount  of  pressure  that  the  heart  can  stand  is 
unknown  to  us.  The  removal  of  even  a  few  ounces  of 
fluid  may  change  the  whole  aspect  of  the  case,  and  if  the 
effusion  be  purulent  or  sero  purulent,  there  is  no  hope 
that  it  will  be  absorbed.  These  three  reasons  must 
appeal  to  all  surgeons  in  favour  of  operation  before 
the   effusion    has   become    so    larsre    as    it   was   in    Dr. 


'  Kidd,  "  Med.  Soc.  Trans.,"  1895,  xviii.,  p.  189  ;  Ogle,  loc.  cit. 

^  This  patient,  also,  recovered  without  operation.  We  must 
note  that  the  case  was  reported  in  1873,  when  the  fear  of 
'  untoward  circumstances  '  was  greater  than  it  is  now. 


PERICARDIAL    EFFUSIONS.  39^ 

Ogle's  case;  but  this  is  hardly  a  question  for  them  to 
decide.^ 

The  whole  subject  is  fully  discussed  in  Dr.  West's 
account  of  80  cases  (181 9-1 883)  of  pericardial  effusion 
treated  by  operation.  Of  7 1,  where  the  sex  of  the  patient 
was  known,  57  were  males,  and  14  females.  Of  67, 
where  the  age  was  known,  7  were  under  10,  20  were 
under  20,  28  under  30,  7  under  40,  i  under  50,  i  under 
60,  and  3  under  70.  The  diseases  with  which  it  was 
associated  were  as  follows- : — 

I.  Rheumatic  Fever.— 'EA&v&n  cases:  seven  made  a  com- 
plete recovery,  one  lived  6  months,  one  lived  6  days  ;  in  one, 
the  operation  was  not  done  till  the  patient  was  moribund ; 
and  in  one,  the  trochar  penetrated  the  right  ventricle,  and 
the  patient  died  in  a  few  minutes.  Only  a  few  ounces  of 
fluid  were  removed,  except  in  one  case  where  the  amount 
removed  was  two  pints.  Very  great  relief  was  given  by  the 
operation. 

■  2.  Phthisis.  — i:\nr\.&ex\  cases,  of  which  seven  had  also 
pleuritic  effusion.  In  all,  the  pericardial  effusion  was  serous ; 
in  most  of  them,  only  a  few  ounces  were  removed  ;  but  m 
five,  the  amounts  were  22,  27,  28,  35,  and  49  ounces.  Four 
were  so  far  relieved  as  to  be  put  down  as  recoveries  ;  two 
lived  over  two  months,  one  nearly  a  month,  two  died  a  (tw 
hours  or  days  after  the  operation. 

3.  Scorbtittis.—Km&  cases,  all  males.     In  all,  the  effusion 

1  Sir  Grainger  Stewart  {loc.  cit.)  points  out  that  if  there  are 
indications  that  the  heart  itself  has  become  weakened  by  the 
general  inflammation,  one  ought  to  operate  even  though  the 
effusion  be  not  very  large;  and  to  be  especially  careful  not  to 
draw  off  too  large  a  quantity  of  it. 

=  These  cases  come  to  79  in  all ;  the  80th  case,  which  is  put  at 
the  end  of  Dr.  West's  tables,  but  came  too  late  to  be  incorpo- 
rated in  his  paper,  was  a  case  of  pyaemia,  under  the  care  of  Sir 
William  Savory,  with  abscesses  in  the  shoulder  and  thigh,  and  left 
pleural  effusion.  This  was  twice  tapped,  then  a  free  incision  was 
made  through  the  fifth  space  in  the  anterior  axillary  line.  No 
fluid  was  found,  but  the  pericardium  was  felt  to  be  distended,  and 
was  opened  then  and  there  through  the  same  wound.  Twenty- 
four  ounces  of  pus  were  let  out,  and  the  patient  was  much 
relieved  :  he  died  a  fortnight  later.     "Trans.  Path.  Soc,"  18  4. 


392  SURGERY    OF    THE    CHEST. 

was  hcemorrhagic  ;  in  all,  the  amount  of  it  was  very  large — 
from  1^  to  5  pints.  Six  made  a  complete  recovery;  one  died 
a  few  hours  after  operation,  two  at  later  periods  after  it. 

4.  Pletcrisy. — Six  cases :  in  two  of  them,  one  of  which  was 
a  case  of  empyema,  the  pericardial  effusion  was  purulent. 
Only  one  recovered,  but  most  of  them  were  relieved. 

5.  General  Dropsy. — Five  cases :  two  from  morbus  cordis, 
both  died  ;  two  from  nephritis,  both  recovered  ;  one  from 
general  bronchitis,  recovered. 

6.  Pneiimo7iia. — Two  cases :  in  both,  the  effusion  was 
purulent,  and  probably  of  a  pysemic  origin. 

7.  Miscellaneous. — Three  cases  followed  exposure  to  cold, 
a  surgical  operation,  and  a  new  growth  in  the  mediastinum  ; 
and  one  was  referred  to  an  injury. 

8.  Unassigned. — Seventeen  cases  :  six  recovered,  eleven 
died.  In  six,  a.  post  inortein  examination  was  made  ;  in  four 
of  these,  the  pericarditis  was  found  to  be  due  to  tubercular 
disease';  in  one  there  was  double  hydrothorax  ;  in  one,  a 
pericardial  effusion  with  adherent  pleura. 

9.  Purulent  Pericarditis. — Twelve  cases :  all  fatal,^  except 
two  that  were  treated  by  free  incision.  All  males :  out  of 
ten,  whose  ages  were  recorded,  seven  were  between  10  and 
20  years  old,  and  the  oldest  of  all  was  only  31.  Six  of  the 
twelve  were  probably  pyasmic  ;  two  were  associated  with 
empyema,  though  in  one  of  these  the  empyema  was  subse- 
quent to  the  operation.  In  none  of  them  was  the  character 
of  the  fluid  diagnosed  before  the  operation,  nor  do  there  seem 
to  have  been  any  physical  signs  by  which  this  could  have 
been  done.^  In  some,  the  operation  was  repeated  more 
than  once — in  one,  six  times.  The  quantity  of  pus  removed 
varied  a  good  deal,  but  the  average  was  higher  than  with 
serous  effusions. 

The  results  of  operation,  thus  admirably  set  forth,  are 
full  of  encouragement,  when  we  consider  the  hopeless 


'  In  the  cases  of  tubercular  pericarditis  recorded  in  Dr.  West's 
tables,  the  effusion  was  serous,  never  purulent  or  haemorrhagic. 

^  In  Ponroy  and  Fremy's  case  {1870)  the  effusion,  though 
purulent  or  sero-purulent,  was  cured  by  aspiration.  Twenty- 
eight  ounces  were  removed.  The  case  is  given  in  Dr.  Ogle's 
paper,  and  is  No.  32  in  Dr.  West's  tables. 

3  It  is  to  be  remembered  that  the  temperature  may  be  normal, 
even  with  pus  in  the  pericardium. 


PERICARDIAL    EFFUSIONS.  393 

condition  of  these  patients.  Two  points  are  especially 
to  be  noted — the  great  relief  given  by  it  in  cases  where 
it  still  failed  to  save  life,  and  the  good  results  obtained 
by  the  withdrawal  of  even  a  small  quantity  of  fluid. 

Operation. 

We  have  to  reckon  with  the  fear  of  wounding  the 
heart.  In  one  of  the  eighty  cases,  two  ounces  of  blood 
came  through  the  cannula,  and  the  patient  died  in  a  few 
minutes  :  the  right  ventricle  had  been  torn,  about  the 
middle  of  its  anterior  aspect.  In  another  (1868)  ten  and 
a  half  ounces  of  blood  came  through  the  cannula,  the 
left  pleura  was  also  wounded,  and  the  patient  died 
in  two  hours  ;  more  than  half  a  pint  of  blood  was  found 
in  the  pleura.  In  three  others,  the  heart  was  slightly 
wounded,  but  no  harm  was  done  ;  in  one  of  them,  a 
girl,  1 1  years  old,  where  puncture  was  made  on  eight 
separate  occasions,  the  heart  was  wounded  twice. 

The  place  of  puncture  has  been  made  the  subject  of 
much  debate ;  every  space  from  the  second  to  the  eighth 
has  been  used  for  it.  Steavenson  wrote  in  favour  of  the 
third  space,  because  the  fluid  distends  the  pericardial 
cul-de-sac  at  the  root  of  the  aorta.  Rotch  has  advocated 
the  fifth  space,  on  the  right  side,  about  half-an-inch  from 
the  sternum.  Dr.  West's  cases  give  the  following  sites  of 
puncture:  in  30,  the  fifth  space;  in  20,  the  fourth:  in 
3,  the  sixth  ;  in  3,  the  third  ;  in  i,  the  seventh  ;  and  in 
I,  the  eighth.  We  can  hardly  be  surprised  that  this  last 
was  a  '  dry  tapping.'  And  in  3,  the  third  or  fifth  right 
space  was  chosen.  But  we  need  not  let  these  exceptional 
procedures  disturb  the  general  rule.  We  must  keep  to 
the  outer  side  of  the  internal  mammary  artery,  and  the 
inner  side  of  the  lung  ;  and,  unless  there  be  some  special 


394  SURGERY    OF    THE    CHEST. 

reason  for  going  elsewhere,  the  best  point  is  the  fifth  left 
space,  one  inch  from  the  sternum. ^ 

It  may  be  dangerous  to  give  an  ansesthetic.  I  once, 
when  a  student,  saw  death  follow  the  use  of  a  small 
quantity  of  chloroform,  in'  the  case  of  a  boy  with  peri- 
cardial effusion,  just  as  the  exploring  syringe  had  been 
inserted  :  the  heart  was  not  wounded.  Bouveret-  quotes 
a  case  of  death  from  shock,  during  an  attempt  to  punc- 
ture the  pericardium  : — 

A  young  man,  who  during  eight  years  bad  suffered  four 
attacks  of  acute  rheumatism,  with  heart-complications,  was 
admitted  to  Hospital  with  extreme  dyspnoea,  and  signs  of 
pericardial  effusion.  An  aspirating  needle  was  passed 
through  the  third  right  space  (!)  an  inch  and  a  half  deep. 
No  fluid  escaped ;  the  needle  was  felt  to  move  with  the 
movements  of  the  heart.  The  patient  cried  out,  drew  a  deep 
breath,  turned  livid,  then  pale,  and  died.  The  posi  mortem 
examination  showed  that  the  needle  had  passed  into  the 
anterior  mediastinal  space,  and  had  become  fixed,  not  in 
the  heart,  but  in  the  pericardium,  which  was  very  thick  and 
hard,  and  almost  universally  adherent  ;  there  was  a  huge 
sero-purulent  pericardial  effusion,  nearly  a  quart,  untouched. 

Here  we  have  two  deaths,  one  under  chloroform,  the 
other  without  it.  On  the  whole,  I  think  cocaine  (not 
only  applied  to  the  skin,  but  also  injected  under  it)  would 
be  safer  than  a  general  ansesthetic,  or  it  might  suffice  to 
freeze  the  skin  ;  but  there  is  no  general  rule  on  this 
point. 

In  every  case,  an  exploratory  puncture  must  first  be 

'  "  If  the  pleura  be  adherent,  the  puncture  may  be  made  safely 
much  further  out,  and  even  in  the  sixth  space." — Dr.  West. 

It  is  certainly  bad  advice  that  one  should  go  as  near  the 
sternum  as  possible :  Dr.  Drury,  of  Dublin,  has  shown  by 
numerous  dissections  that  by  doing  this  one  would  be  in  great 
danger  of  wounding  the  internal  mammary  artery  or  its  vein. 
See  "  Brit.  Med.  Journ.,"  May  30th,  1896. 

^  Traite  de  I'Empyeme.  The  reference  is  to  "  L'Union  Medi- 
cale,"  1878. 


PERICARDIAL    EFFUSIONS.  395 

made.  For  the  withdrawal  of  the  fluid,  aspiration  is 
not  necessary  :  there  is  no  question  here  of  negative 
pressure,  such  as  may  make  a  failure  of  simple  puncture 
of  the  pleura  without  aspiration.  Whatever  instrument 
is  used,  it  must  be  a  very  fine  one.  If  the  aspirator  be 
used,  of  course  the  needle  must  be  guarded  with  its 
cannula,  and  no  vigorous  suction  must  be  made. 

Shall  the  surgeon  withdraw  only  a  few  ounces  of  the 
effusion,  or  all  of  it  ?  It  is  true  that  the  withdrawal  of 
only  a  few  ounces  may  suffice  not  only  to  give  relief,  but 
also  to  set  up  absorption  of  the  remainder.  And  it  has 
been  urged  that  withdrawal  of  the  whole  of  a  large  peri- 
cardial effusion  may  cause  syncope.  But  we  cannot 
argue  from  a  pleural  to  a  pericardial  effusion  ;  and  I  can 
find  no  evidence  that  syncope  is  likely  to  follow  the 
withdrawal  of  the  whole  of  the  fluid,  however  much  it 
may  be,  from  the  pericardium. i 

A  small  incision  must  be  made  through  the  skin  ;  the 
needle  must  not  be  driven  inward  with  a  stab ;  and,  if 
the  aspirator  or  an  aspirating  syringe  be  used,  a  vacuum 
should  be  made  before  the  pericardium  is  reached.  If 
there  be  much  oedema  of  the  soft  parts,  it  may  be  hard 
to  hit  off"  the  space.  In  Ponroy  and  P>emy's  case,  owing 
to  this  difficulty,  the  needle  was  thrust  throiigh  one  of 
the  costal  cartilages,  instead  of  going  between  them, 
and  got  plugged  with  a  wad  of  cartilage,  so  that  the 
effusion  escaped  not  through  but  by  the  side  of  it. 

Finally,  we  come  to  the  treatment  of  purulent  peri- 
carditis   by   incision    and   drainage.      It   may   be   that 

'  In  a  very  interesting  case  of  purulent  pericarditis,  treated 
three  times  by  aspiration,  and  finally  by  incision  and  drainage 
(Dr.  Dickinson.  "Clin.  Soc.  Trans.,"  1889.  xxii.,  48),  the  patient 
became  faint  during  aspiration  on  the  second  occasion,  but  no 
mention  is  made  of  his  fainting  on  the  third  occasion,  a  week 
later,  when  a  still  larger  quantity  of  fluid  was  withdrawn. 


396  SURGERY    OF    THE    CHEST. 

incision  will  come  to  be  used  for  some  cases  of  effusion 
not  purulent.  After  all,  we  can  hardly  draw  a  line 
between  making  an  incision  through  the  skin  to  ease  the 
passage  of  the  needle,  and  making  an  incision  down  to 
the  pericardium.  However  this  may  be,  it  is  certain  that 
a  purulent  effusion  must  be  incised  and  drained.  The 
pus  sometimes  contains  fibrinous  clots,  and  these  have 
been  known  to  give  trouble.^  In  one  case,  irrigation  was 
employed  during  the  operation,  on  account  of  them. 
Unhappily,  the  fluid  syringed  into  the  pericardium  col- 
lected within  it,  and  the  patient  died  during  the  operation. 
In  this  case,  a  piece  of  costal  cartilage  was  resected,  and 
the  pericardium,  before  it  was  opened,  was  sutured  to 
the  chest-wall. 

It  is  not  likely  that  the  surgeon  will  proceed  straight 
to  incision  and  drainage  ;  he  will  probably  first  have 
punctured  or  aspirated  the  effusion  once  at  least.  But 
should  he  begin  with  incision,  he  must  remember  that 
the  heart  may  be  adherent  here  and  there  to  the 
pericardium.  I  need  not  quote  at  length  the  records 
of  this  operation  2  ;  it  should  be  done  as  simply  as 
possible,  and  no  more  should  be  done  than  is  absolutely 
necessary.  Drainage  during  the  days  after  operation  might 
be  helped  by  getting  the  patient  to  lie  face  downward. 
It  must  be  kept  up  for  a  considerable  time.     In  Rosen- 


^  '  I  find  on  looking  over  reported  cases,  and  I  know  from 
observation,  how  frequently  the  pus  in  this  form  of  pericarditis  is 
of  a  flocculent,  shreddy  character.'  Mr.  R.  W.  Parker,  loc.  cit. 
Dr.  Ewart  ("  Med.  Soc.  Trans."  1895,  xviii.,  p.  189)  mentions  a 
case  of  purulent  pericarditis  treated  by  aspiration  only,  where 
the  needle  passed  into  a  quantity  of  fibrin,  and  never  reached 
the  mass  of  the  fluid. 

-  Dr.  West  gives  Rosenstein's  case,  with  his  own  ;  otlier  cases 
are  recorded  by  Dr.  Dickinson  and  Mr.  Parker  ("Trans.  Clin. 
Soc,"  1889),  and  Dr.  O'Carroll  ("Brit.  Med.  Journ.,"  May  30th, 
1896). 


PERICARDIAL    EFFUSIONS.  397 

Stein's  case,  the  wound  was  healed  in  three  weeks  ;  in 
Dr.  West's,  the  cavity  was  drained  from  Sept.  17th  to 
Oct.  14th;  in  Dr.  Dickinson's,  from  July  22nd  to  about 
Sept.  2nd.  A  narrow,  sharp-pointed  bistoury  should  be 
used  to  open  the  pericardium,  and  the  admixture  of  a 
little  air  with  the  escaping  pus  does  not  prove  that  the 
lung  has  been  wounded,  for  the  air  may  pass  in  and  out 
of  the  pericardium  with  the  movements  of  the  heart. 
Incision  of  the  pericardium  need  not  be  a  separate 
operation  apart  from  puncture  of  it.  In  Dr.  West's  case, 
the  two  were  done  together,  and  the  cannula  served  as  a 
guide  for  the  bistoury.  It  would  indeed  be  best,  in  a 
case  where  the  effusion  is  known  to  be  purulent,  either 
to  make  incision  at  once,  or  at  least  to  be  prepared  to 
convert  the  puncture  made  by  the  aspirating  needle  into 
an  incision  large  enough  to  admit  a  good-sized  drainage 
tube. 

Malignant  disease  of  the  pericardium  may  so  exactly 
imitate  the  symptoms  and  physical  signs  of  pericardial 
effusion  as  to  lead  to  operation.  This  occurred  in  a 
case  recorded  in  the  "  Transactions  of  the  Pathological 
Society,"  for  1882.  The  trochar,  passed  inward  for  an 
inch-and-a-half,  found  no  fluid,  and  received  no  impulse 
from  the  heart :  several  punctures  were  made  in  vain. 
Finally,  a  probe,  passed  down  the  cannula,  came  against 
a  very  hard  substance.  The  post  mortem  examination 
showed  the  pericardium  to  be  the  seat  of  a  sarcomatous 
growth. 


398 


CHAPTER  XXVI. 

INTRATHORACIC  NEW  GROWTHS.      HYDATID  CYSTS. 
ACTINOMYCOSIS. 

Malignant  Disease. 

It  is  impossible  here  to  attempt  an  account  of  all  the 
forms  of  new  growth  that  may  arise  within  the  chest. 
We  must  keep  within  the  limits  of  operative  surgery, 
and  consider  this  great  subject  only  so  far  as  it  is 
related  to  surgical  interference.  But,  before  we  come  to 
instances  of  operations  done  formally  and  of  set  purpose 
for  the  relief  of  some  of  these  diseases,  we  have  to  note 
a  very  important  group  of  cases  where  the  diagnosis  has 
been  wrong,  and  the  surgeon  has  mistaken  a  new  growth 
for  a  pleural  effusion,  or  vice  versa. 

It  cannot  often  happen  that  an  effusion  should  be  mis- 
taken for  a  new  growth  :  but  the  following  cases^  show 
how  this  may  be  done  : — 

1.  A  very  decrepit  old  man,  75  years  of  age,  applied  for 
admission  to  Hospital.  He  was  suffering  extreme  shortness 
of  breath,  there  was  absolute  dulness  over  the  whole  right 
side  of  the  chest  in  front,  absolute  loss  of  breath-sounds  and 
of  vocal  vibration,  hardly  any  displacement  of  heart  or  of 
liver,  several  hard  enlarged  glands  above  the  right  clavicle, 
no  history  of  illness,  no  pain,  only  weakness.  "  I  felt  sure  it 
was  a  new  growth,  but  puncture  showed  it  was  a  large  hccmor- 
rhagic  pleural  effusion." 

2.  A  young  man,  aged  20,  was  admitted  to  Hospital  with 
symptoms  of  pressure  in  the  mediastinum.  The  diagnosis 
was  made  at  first  of  mediastinal  tumour,  and  later  of  medias- 

^  Frantzel,  "Ziemssen'sHandbuch,"  "Krankheitend.  Pleura," 
1875,  and  Dr.  West's  paper  on  "Purulent  Pericarditis,"  loc.  cit. 


INTRATHORACIC    NEW    GROWTHS,    ETC.         399 

tinal  cyst.  Puncture  let  out  a  quantity  of  clear  serous  fluid, 
which  coagulated,  and  deposited  cholestearin.  The  tapping 
was  repeated  several  times  :  he  died  exhausted  four  years 
and  a  half  after  the  beginning  of  his  illness.  The  posi  mortem 
examination  showed  that  what  had  always  been  regarded 
as  a  mediastinal  cyst  was  really  a  large  chronic  pericardial 
effusion. 

Or  traces  of  an  old  pleurisy  may  be  present  in  the  chest 
of  a  patient  in  whose  case  there  is  some  special  reason  lor 
fearing  malignant  disease  : — 

A  patient,  aged  34,  whose  right  breast  I  had  removed  for 
cancer,  showed  me  a  small  recurrent  nodule  near  the  inner 
angle  of  the  scar.  There  was  also  reason  to  fear  that  the 
ple'ura  was  diseased :  for  over  the  lower  part  of  the  lung,  about 
the  axillary  line,  there  was  a  faint  creaking  sound  on  respira- 
tion, as  if  from  some  thickening  of  the  pleura  :  and  the 
movements  of  that  side  of  the  chest,  and  of  the  lung,  were 
slightly  impaired.  But  it  was  possible  that  these  signs  might 
not  be  due  to  cancer  of  the  pleura.  Where  the  breast  had 
been,  there  was  now  a  thin  rigid  stretch  of  skin  ;  this  might 
cause  the  loss  of  movement  and  of  expansion,  and  the  fnction- 
sound  might  possibly  be  due  to  an  old  pleurisy,  or  to  some 
simple  thickening  of  the  pleura  after  operation.  I  removed 
the  recurrent  nodule,  and  she  is  still,  a  year  later,  in  good 
health. 

But  of  course  the  commoner  error  of  diagnosis  is  to 
mistake  a  ne\v  growth  for  an  effusion,  and  probably  there 
are  few  physicians  of  really  great  experience  who  have 
not  made  this  mistake  once,  or  more  than  once.^ 

A  girl,  aged  17,  came  under  my  care  in  January  1894,  with 
subperiosteal  sarcoma  (myxo-chondro-sarcoma)  of  the  lower 
end  of  the  right  femur,  and  I  did  an  amputation  through  the 
middle  of  the  thigh.  I  saw  her  afterward  from  time  to  time 
during  1894,  and  she  kept  in  good  health  :  once  she  com- 
plained of  some  pain  in  her  left  side,  but  this  soon  passed  off. 
Just  a  year  after  the  operation,  January  1895,  she  was  seized 

'  '  Three  times  at  least '  says  one  of  them,  '  I  have  been  dis- 
tinctly wrong  in  diagnosing  pleural  effusion  where  intra- thoracic 
tumour  was  present,  and  many  times  my  doubts  have  only  been 
removed  by  the  results  of  exploration.' 


400  SURGERY    OF    THE    CHEST. 

with  a  sharp  pain  in  her  le/if  side,  and  shortness  of  breath,  and 
her  medical  attendant  found  all  the  physical  signs  of  a  pleural 
effusion;  but  she  had  no  cough,  no  shivering,  and  but  little 
pain.  After  some  weeks  at  home,  she  was  admitted  to 
Hospital  under  the  care  of  one  of  the  physicians.  The 
heart  was  pushed  far  over  to  the  right  of  the  sternum, 
and  there  was  every  sign  of  a  huge  effusion  into  the  left 
pleura.  The  veins  over  the  left  side  of  the  chest  were  not 
dilated,  the  left  lower  limb  was  not  oedematous.  Nothing  but 
blood  was  drawn  on  aspiration,  but  a  flake  of  tissue  came  away 
in  the  eye  of  the  needle,  which  under  the  microscope  showed 
small  round  cells.  A  few  days  later,  under  ether,  an  incision 
was  made  through  the  pleura,  and  came  down  on  a  solid 
growth.  She  nearly  died  during  this  small  operation  ;  for 
several  minutes  her  breathing  was  almost  at  a  standstill,  all  the 
accessory  muscles  of  respiration  appearing  to  be  tugging  at 
the  ribs  without  lifting  them.  The  use  of  oxygen  revived  her ; 
she  lived  about  a  week  longer,  without  much  pain,  and  the 
oxygen  never  failed  to  relieve  her  dyspnoea.  Post  mortem., 
there  was  a  huge  mass  of  osteo-sarcoma  filling  the  whole  left 
side  of  the  chest,  and  showing  the  print  of  the  ribs,  diaphragm, 
and  left  kidney,  like  plaster  run  into  a  mould.  Only  the 
uppermost  part  of  the  lung  remained,  and  this  was  hollowed 
out  into  a  cyst  full  of  blood.  The  disease  had  invaded  the 
anterior  mediastinum,  the  base  of  the  right  lung,  the  lower 
ribs  on  the  right  side,  and  the  spine.  There  was  also  recent 
fibrinous  pericarditis. 

In  the  two  following  cases  i — which,  like  my  own, 2  are 
examples  of  sarcoma  of  lung  after  sarcoma  of  bone  of 
lower  limb — the  diagnosis  was  made  easy  by  the  patient 
coughing  up  fragments  of  the  growth. 

I.  A  man,  aged  21,  underwent  amputation  above  the  knee 
joint,  in  February  1887,  for  a  hemorrhagic  myeloid  sarcoma 
in  the  head  of  the  left  tibia.  In  June  of  the  same  year,  he 
coughed  up,  without  pain,  a  dark-red  mass  the  size  of  his 

^  Hiiber,  "  Ueber  Lungensarkom."  "  Zeitschr.  f.  Klin.  Med.," 
1890,  p.  341.  In  medullary  cancer,  whitish  fragments,  like  '  mor- 
sels of  cooked  veal,'  have  in  one  or  two  cases  been  coughed  up. 
For  references,  see  Moutard-Martin,  "  Etude  sur  les  Pleuresies 
Hemorrhagiques,"  1878,  p.  52. 

=  See  Dr.  H.  B.  Meakin's  paper  on  "Sarcoma  of  Lung," 
"Path.  Soc.  Trans.,"  1895. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        401 

finger-tip.  A  fortnight  later,  another  somewhat  larger  mass ; 
a  week  later,  another,  with  some  blood.  Henceforward  this 
coughing  up  of  fragments  of  the  growth,  with  haemoptysis, 
became  more  frequent.  He  had  a  little  pain  in  his  left  side 
when  he  coughed,  and  he  was  losing  flesh.  On  August  22nd, 
he  was  admitted  to  Hospital.  His  respiration  was  quiet, 
regular,  and  the  same  on  both  sides.  There  was  slight 
dulness  on  percussion  over  the  left  interscapular  space,  and 
the  breath-sounds  here  were  somewhat  loud,  with  well-marked 
rales  heard  mostly  during  inspiration.  No  enlarged  glands, 
no  tenderness  over  the  ribs,  no  fever,  occasional  cough  with 
hccmoptysis.  August  27th,  he  coughed  up  an  ounce  and  a 
half  of  bright  frothy  blood,  with  two  dark  reddish-brown 
masses,  about  the  size  of  the  end  of  one's  thumb.  These  con- 
tained giant-cells,  and  large  single  cells  with  active  nuclei. 
September  2nd,  htemoptysis,  nearly  two  ounces,  with  two 
similiar  masses.  There  was  never,  at  this  time,  any  fever. 
September  26th,  haemoptysis,  more  than  half-a-pint,  with  a 
large  mass  of  the  growth.  Exploratory  puncture  drew  off 
some  turbid  blood-stained  fluid  ;  no  cells  were  found  in  it. 
From  September  to  November,  he  had  six  attacks  of  hsemo- 
ptysis,  with  expulsion  of  fragments  of  the  growth  ;  as  a  rule, 
the  haemorrhage  followed  the  expulsion.  In  November,  a 
growth  appeared  in  the  right  gluteal  region.  His  tempera- 
ture became  hectic,  and  he  died  exhausted  at  the  end  of  the 
month.  The  post  mortem  examination  showed  huge  enlarge- 
ment of  the  left  lung  with  a  mass  of  dark-red  growth,  filling 
the  lung  from  root  to  surface,  breaking-down  centrally,  cram- 
ming the  main  bronchus,  and  the  main  artery  of  the  lower 
lobe.  The  right  lung  also,  its  bronchi  and  vessels,  were 
invaded,  and  there  was  a  secondary  growth  in  the  left  occipi- 
tal lobe  of  the  brain. 

2.  A  boy,  aged  16,  underwent  amputation  for  osteo-sar- 
coma  of  the  left  knee-joint.  Three  years  later,  he  was  taken 
ill,  with  the  general  appearances  of  rheumatic  fever,  but  got 
well  in  about  a  week.  Ten  days  later  he  had  a  similar  attack, 
and  this  time  he  complained  of  pains  in  the  left  side  of  the 
chest.  Four  days  later  he  had  a  slight  heemoptysis,  and  a 
few  days  afterward  he  coughed  up  what  looked  like  a  long 
thin  blood-clot.  He  got  better  for  a  time,  and  left  the  Hos- 
pital ;  but  in  a  few  weeks  he  was  re-admitted  with  pain, 
fever,  haemoptysis,  and  pleural  eflusion.  A  similar  strip  of 
tissue  was  coughed  up,  and  was  found  to  be  round-celled 
sarcoma.  Before  his  death,  he  had  on  four  occasions  coughed 
up  fragments  of  the  growth. 

26 


402  SURGERY    OF    THE    CHEST. 

These  three  cases  may  serve  to  show  that  we  must 
always  bear  in  mind  the  possibility  of  malignant  disease, 
if  a  patient,  who  has  in  past  years  undergone  operation 
for  it,  shows  signs  of  trouble  in  the  chest. ^  We  must 
also  make  careful  microscopic  examination  of  the  sputa, 
though  as  a  rule,  cancer-cells  are  not  to  be  found  in  them  ; 
but  they  may  be  stained  with  blood."  And  very  careful 
search  must  be  made  for  some  unsuspected  primary 
growth.  Cases  have  been  recorded,  for  example,  of 
cancer  of  the  lung  secondary  to  cancer  of  the  vagina,  the 
stomach,  the  pancreas,  one  of  the  ovaries,  or  one  of  the 
suprarenal  capsules. 

The  absence  of  fever  may  suggest  that  the  case  is  one 
of  malignant  disease,  not  of  pleuritic  effusion.  But  in  the 
last  stages  of  rapid  malignant  disease,  either  in  the  lung 
or  elsewhere,  there  may  be  fever  of  a  hectic  type :  or  the 
patient  may  be  feverish  from  an  infected  pleural  effusion 
j>/us  malignant  disease.  And  he  is  especially  likely  to 
be  feverish  if  he  is  a  child. 

I.  A  little  boy,  3^  years  old,  was  taken  ill  in  March,  with 
slight   feverish   symptoms,  and  signs  resembling   those   of 

'  Borck  ("  Deutsch.  Ges.  f.  Chin,"  i8go)  collected  notes  of 
87  cases  of  sarcoma  of  the  femur  treated  by  amputation  at  the 
hip-joint.  He  was  unable  to  find  one  among  all  of  them  where 
it  was  certain  that  the  disease  did  not  recur  within  three  years. 
I  have  only  once  amputated  through  the  hip-joint  for  this  disease. 
The  patient  was  in  good  health  when  I  last  saw  her,  four  years 
after  the  operation.  A  recent  paper  by  Mr.  Butlin  and  Mr.  Colby, 
"  St.  Bart.  Hosp.  Rep.,"  1895,  shows  that  out  of  40  cases  of  sar- 
coma of  the  femur,  only  3  were  alive  three  years  after  amputation. 

=  They  may  have  a  peculiar  character,  the  blood  being  so 
intimately  mixed  with  thin  mucous  or  serous  fluid  that  the  sputa 
look  like  red-currant  juice.  See  Burrows,  "Trans.  Med.  Chir. 
Soc,"  1844,  and  Kidd,  "St.  Bart.  Hosp.  Rep.,"  1883,  xix.,  227. 
One  finds  them  described  as  '  thin  reddish  mucus  resembling  red- 
currant  jelly,'  or  as  'at  first  mucus  streaked  with  blood  and 
clots  of  blood,  but  latterly  more  uniformly  bloody,  and  of  a 
peculiar  pink  colour.' 


INTRATHORACIC    NEW    GROWTHS,    ETC.        403 

pleurisy  of  the  left  side.  He  gradually  became  worse,  till 
there  was  complete  dulness  over  the  left  side,  with  remittent 
fever.  On  April  14th,  an  exploratory  puncture  drew  off  only 
some  blood-stained  serum.  Three  days  later,  the  eighth  rilj 
was  resected  in  the  axillary  line,  and  a  solid  growth  was  found 
filling  the  pleural  cavity.  On  April  20th  he  died,  and  the 
posl  nwTieni  examination  showed  a  huge  mass  of  myxo-sar- 
coma  arising  from  the  left  pleura.' 

2.  A  boy,  aged  12,  after  four  months'  illness  (pains  in  the 
chest,  cough,  and  latterly  haemoptysis)  was  admitted  to  Hos- 
pital in  June,  with  signs  of  malignant  disease  in  the  left  side 
of  the  chest,  and  died  at  the  end  of  September.  His  temper- 
ature exhibited  a  very  marked  rise  every  morning,  often  to 
102  or  103,  falling  every  evening  to  normal,  e.g..  during  June 
the  daily  rise  and  fall  ranged  through  6'8  degrees,  the  usual 
difference  between  the  highest  and  lowest  temperatures  in  the 
24  hours  being  4  or  4*5  degrees.  During  this  period  he 
sweated  profusely. 

In  his  notes  on  this  second  case,  Dr.  Church  refers  to 
other  similar  instances  of  fever  during  the  course  of  lymph- 
adenoma  of  the  mediastinum.  In  one  of  them,  a  girl 
17  years  old,  the  temperature  for  two  months  was  often 
102  or  103,  but  the  fever  became  less  as  the  disease 
advanced  toward  death. 

Nor  can  the  diagnosis  between  malignant  disease 
and  pleural  effusion  be  made  by  noting  the  presence  or 
absence  of  pressure  on  the  chest-wall.  In  the  later  stages 
of  malignant  disease,  there  may  be  retraction  of  the  chest- 
wall;  but  the  exact  opposite  to  this  may  happen.  There 
is  no  constant  rule  in  this  matter,  and  if  effusion  and 
malignant  disease  are  both  present  together,  the  signs  of 
the  former  may  wholly  mask  those  of  the  latter. 

Putting  aside  such  evident  indications  as  a  history  of 
some  previous  operation  for  malignant  disease,  or  the 
presence  of  a  new  growth  in  some  other  region  of  the 

'  Hofmokl,  "  Chirurgie  der  Pleura  und  der  Lungen,"  1890. 
Dr.  Church,  A  Case  of  Intra-thoracic  Tumour,  "  St.  Bart, 
llosp.  Rep.,"  1878,  xiv.,  242. 


404  SURGERY    OF    THE    CHEST. 

body,  or  the  expectoration  of  fragments  of  the  tumour,  we 
have  no  sure  or  constant  sign  by  which  to  know  whether 
we  have  to  deal  with  pleural  effusion  or  malignant  disease. 
It  is  of  course  easy  to  think  of  those  distinctive  characters 
that  we  should  expect  to  find  in  a  solid  growth  and  not 
in  an  effusion.  '  The  area  of  dulness  is,  as  a  rule,  less 
regular.  It  is  not  in  all  cases  most  marked  at  the  lowest 
level  of  the  pleura.  Its  upper  level  does  not  alter  when 
the  patient  changes  his  posture.  It  does  not  stand  higher 
at  one  time,  lower  at  another,  like  a  pleural  effusion.' i 
But  the  literature  of  surgery  contains  so  many  examples 
where  the  one  was  mistaken  for  the  other,  that  there  is 
plainly  no  sure  method  of  diagnosis  in  these  cases. 

We  come  then  to  exploratory  puncture  as  the  best 
guide  toward  recognizing  the  disease.  If  no  fluid  comes 
out,  the  needle-point  must  be  carefully  examined :  a 
small  fragment  of  the  growth  may  be  found  sticking  in  it. 
If  only  a  few  drops  of  blood  are  drawn  into  the  exploring- 
syringe,  and  the  needle  does  not  seem  to  move  freely  in 
a  cavity,  our  fear  of  malignant  disease  must  be  heightened. 
But,  if  we  take  those  cases  where  pleural  effusion  and 
malignant  disease  are  both  present  together,  what  is 
likely  to  be  the  character  of  the  effusion  under  these 
circumstances  ? 

The  answer  to  this  question  is  given  in  Moutard- 
Martin's  admirable  monograph  on  '  Hsemorrhagic  Pleu- 
risies,'2  and  his  work  should  be  carefully  studied.  He 
collected  notes  of  42  cases  of  cancer  of  the  lung,  or  of  the 

'Frantzel,  "  Ziemssen's  Handbuch."  See  also  Dr.  Poore, 
"Lancet,"  April  6th,  1895,  and  Dr.  Martin,  "  St.  Bart.  Hosp. 
Rep.,"  1865,  vol.  i.,  p.  262,  for  good  accounts  of  the  almost 
insuperable  difficulty  of  diagnosis  in  some  instances  of  intra- 
thoracic malignant  disease. 

=  "  Etude  sur  les  Pleuresies  HImorrhagiques,  Neo-membran- 
euse,  Tuberculeuse,  et  Cancereuse,"  Paris,  1878,  p.  162. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        405 

pleura,  or  of  both  together ;  in  some  of  them  the  disease 
was  primary,  but  in  the  majority  it  was  secondary.  Out 
of  the  42,  in  37  there  was  no  effusion,  in  6  it  was  serous, 
and  in  i  only  it  was  sanguinolent,  and  in  this  case  only 
at  the  second  puncture.^  To  these  42  cases,  collected 
from  the  "  Bulletins  de  la  Society  Anatomique,"  he 
added  cases  recorded  in  other  journals,  and  from  the 
whole  collection  of  more  than  200  cases  he  finds  that,  on 
an  average,  in  malignant  disease  of  the  lung  or  the 
pleura,  effusion  is  present  in  3  cases  out  of  8 ;  when 
present,  it  is  serous  in  2  out  of  3,  and  hsemorrhagic  in 
the  third.  The  surgeon  must  not  expect  to  find  cancer- 
cells  in  the  fluid  thus  withdrawn:  the  search  for  them 
has  very  rarely  been  successful.^ 

An  analysis  of  19  cases  of  malignant  disease  of 
the  lung  or  mediastinum  (Victoria  Park  Hospital, 
1886-1892)  by  Dr.  Vincent  Harris.''  gave  the  following 
diagnostic  results  :  In  every  case  there  was  more  or  less 
difficulty  of  breathing.  Pain  was  well-marked  in  only  a 
few  ;  cough  was  present  in  most,  if  not  all,  and  in  many 
was  spasmodic  and  distressing.  Only  in  a  few  were  the 
sputa  at  all  tinged  with  blood,  or  the  character  of  the 
voice  changed.  In  two,  there  was  dysphagia ;  in  five, 
some  localized  oedema.  Inequality  of  the  pupils,  or  of 
the  radial  pulses,  was  rarely  observed.  Only  one  or  two 
of  the  cases  showed  fulness  of  the  side  of  the  chest,  or 
of  some  intercostal  spaces,  or  below  the  clavicle.     The 

'  The  reader  will  observe  that  37  +  6  + 1  =  44  not  42.  I  can  only 
suppose  there  is  a  misprint  in  the  original. 

^  Dr.  R.  G.  Hebb,  in  a  case  of  primary  cancer  of  the  pleura, 
drew  off  a  pint  and  a  half  of  blood-stained  effusion,  and  with  the 
microscope  found  one  stray  cell  from  the  growth.  "  Path.  Soc. 
Trans.,"  1893,  p.  5. 

3  "  Intra-Thoracic  Growths,"  "  St.  Bart.  Hosp.  Rep.,"  1892,  vol. 
xxviii.,  p.  73.  In  nearly  every  case  the  disease  was  primary 
sarcoma. 


4o6  SURGERY    OF    THE    CHEST. 

most  constant  sign  was  the  area  of  absolute  and  resisting 
dulness,  irregular  in  size  and  shape,  merging  into  the 
prsecordial  dulness,  and  not  altering  with  any  change  of 
position  of  the  patient.  The  onset  of  the  disease  was  in 
most  cases  very  insidious  ;  and,  in  two  or  three,  there 
were  continued  fever  and  occasional  night  sweats. 

Pleurisy  with  effusion  occurred  in  several  cases ; 
gangrene  of  the  lung  in  two  ;  pericarditis,  with  blood- 
stained effusion,  in  two  ;  obliteration  of  veins  or  arteries 
in  two  or  more  ;  pneumonia  in  three. 

The  pathology  of  the  intra-thoracic  growths  is  not  here 
our  concern  :  nor  are  pathologists  wholly  agreed  regarding 
their  origin  ;  whether,  for  example,  a  diffuse  malignant 
growth  can  arise  in  the  endothelial  cells  of  the  pleura; 
whether  we  can  draw  a  valid  distinction  between  sarcoma 
and  lympho-sarcoma.  We  have  to  consider  only  what 
hope  can  be  offered  to  these  cases  by  surgery.  The 
most  that  can  be  done,  and,  so  far  as  we  can  see,  that 
ever  will  be  done,  is  to  withdraw  the  effusion.  The  one 
or  two  procedures  of  a  more  serious  nature  that  have 
been  recorded  have  been  rather  matters  of  chance  than 
formal  operations.  How  great  relief  may  be  given  by 
aspiration  is  shown  by  a  case  recorded  by  Sir  William 
Broadbent  ^  of  withdrawal  of  two  quarts  of  deeply 
blood-stained  fluid  from  the  chest  of  a  man,  aged  76, 
who  was  able,  for  more  than  six  months  afterward,  to  be 
about  and  at  work,  in  spite  of  his  disease ;  and  by  Dieu- 
lafoy's  case,  where  aspiration  was  done  twenty-five  times. 
It  is  advisable  to  draw  off  the  fluid  slowly,  and  not  to  feel 
bound  to  remove  it  all.  Apart  from  the  danger  of  causing 
haemorrhage   from    the  growth  or  from    its    adhesions, 

'"A  Case  of  Rapid  Effusion  of  Bloody  Fluid  into  the  Right 
Pleural  Cavity,  at  the  age  of  76." — "Clin.  Soc.  Trans.,"  1878, 
vol.  xi.,  p.  136. 


INTRATHORACIC    NEW    GROWTHS,    ETC.         407 

aspiration  has  once  or  twice  in  these  cases  been  followed 
by  that  profuse  serous  expectoration,  which  has  been 
described  in  Chap.  xiv.  The  quantity  of  fluid  may  be 
very  large — even  6  or  7  pints.  Should  the  effusion 
become  purulent  or  semi-purulent,  it  may  be  necessary  to 
employ  incision  and  drainage.  And,  if  I  may  judge 
from  one  case  where  I  tried  oxygen,  the  administration 
of  it  is  likely  to  give  great  relief  in  the  later  stages  of 
extensive  malignant  disease  of  the  chest. 

Dermoid  Cysts. 

Dermoid  cysts  have  been  recorded  in  the  lung  and  in 
the  anterior  mediastinum,  and  have  been  treated  by 
operation.  Out  of  42  cases  of  mediastinal  new  growth 
given  by  Rumpf,'  33  were  sarcoma  or  carcinoma,  4  were 
fibroma,  and  5  were  dermoid.  Roser  cured  a  case  of 
dermoid  cyst  of  the  mediastinum,  gaining  access  to  it  by 
trephining  the  sternum.  Langenbeck  cured  one  by 
puncture  and  injection  of  iodine.  The  celebrated  case 
of  dermoid  cyst  of  the  lung,  where  Mr.  Godlee  laid 
open  the  cyst,  removed  the  processes  growing  inward 
from  its  walls  into  its  cavity,  and  drained  it,  is  recorded 
in  the  "  Transactions  of  the  Medico-Chirurgical  Society  " 
for  1889,  with  references  to  several  similar  cases.  Only 
a  few  instances  of  this  most  rare  disease  have  been 
recorded,  but  at  least  we  may  note  its  existence,  and  the 
fact  that  it  has  been  several  times  successfully  treated  by 
operation.  We  must  note  that  a  dermoid  cyst  of  the 
anterior  mediastinum  may  transmit  the  impulse  of  the 
heart.     In  a  case  recorded  so  far  back  as  1823,2  the  cyst 

"  Ueber  Neubildungen  im  Mediastinum.'  "  Inaug.  Diss. 
Freiburg,"   1894. 

=  Dr.  Gordon,  "Case  of  Tumour  in  the  Anterior  Mediastinum, 
containing  Bone  and  Teeth."  "  Trans.  Med.  Chir.  Soc,"  1825, 
vol.  xiii.,  p.  12.      The  patient  was  a  young  woman,  21  years  old. 


4o8  SURGERY    OF    THE    CHEST. 

presented  itself  as  a  'small  round  tumour,  below  the 
sternal  extremity  of  the  left  clavicle,  about  the  size  of  a 
nut,  pulsating  regularly  and  strongly.  From  its  appear- 
ances and  situation,  it  was  pronounced,  at  the  consultation 
which  took  place  on  the  case,  to  be  an  aneurysm  of  the 
aorta  or  of  the  arteria  innominata.'  It  finally  pointed 
and  broke,  letting  out  only  serous  fluid.  The  patient 
died  about  a  year  and  a  half  after  the  disease  had  begun 
to  show  itself. 

Hydatid  Disease. 

Next  to  the  liver,  the  lungs  and  pleurae  are  the  most 
common  seat  of  this  disease.  Out  of  loo  cases  of 
hydatid  cyst  ("  Melbourne  Medical  Record,"  March  6th, 
1875)  i'"*  7°  the  liver  was  affected,  in  12  the  lungs,  and 
in  18,  other  parts  of  the  body.  Out  of  74  cases  reported 
by  Dr.  McGillivray,i  65  were  of  the  liver,  and  9  of  the 
lungs.  Whether  the  upper  or  the  lower  portion  of  the 
lung  is  more  often  affected,  is  a  question  that  has  been 
answered  differently  by  different  writers. 

The  disease  may  arise  either  in  the  lung  or  in  the 
pleura,  or  it  may  invade  the  chest  from  the  liver.  Out 
of  31  fatal  cases,  Neisser-  found  11  where  it  began  in  the 
pleura,  8  where  it  began  in  the  lung,  and  12  where 
it  broke  into  the  chest  from  the  liver.  Out  of  1 1  fatal 
cases,  Maydl  found  3  where  it  began  in  the  pleura,  4 
where  it  began  in  the  lung  (in  2  of  these  it  had  burst 
into  the  pleura),  and  3  where  it  burst  into  the  pleura 
from  the  liver ;  in  i  case  its  starting-point  was  not 
made  out. 

In  a  few  cases,  more  than  one  cyst  has  been  found  in 

'  See  Dr.  Greenfield  on  a  "  Case  of  Hydatid  of  the  Lung." 
"Clin.  Soc.  Trans.,"   1877,  vol.  x.,  p.  103. 

^Neisser,  " Die  Echino-Kokkenkrankheit,"  Berlin,  1887. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        409 

the  thoracic  viscera  ;  in  a  few  others,  the  disease  has 
again  begun  to  grow,  long  after  the  patient  had  been 
cured. 

Cases  of  hydatid  of  the  heart  have  been  from  time  to 
time  recorded.  There  is  an  excellent  drawing  of  this 
rare  condition,  at  its  worst,  in  the  "  Transactions  of  the 
Medico-Chirurgical  Society  "  for  1832.1  In  some  cases, 
sudden  death  from  failure  of  the  heart  has  been  noted  ; 
in  Mr.  Evans'  case,  the  patient,  aged  40,  for  five  or  six 
weeks  before  death,  suffered  pain,  dyspnoea,  fainting  fits, 
vomiting,  and  palpitation.  '  The  pulse  was  so  rapid  as  to 
be  countless,  having  the  feel  of  a  continued  vibration  of 
the  vessel,  rather  than  of  a  pulse  ;  the  carotids  and  other 
large  vessels  also  vibrated  strongly.  The  motion  of  the 
heart  was  sudden,  jerking,  and  violent ;  its  force  seemed 
to  increase  under  the  pressure  of  the  hand.  It  was  felt 
over  a  large  extent  of  the  chest,  and  below  the  sternum.' 
In  a  case  lately  reported  in  the  "  Lancet,"  ~  there  were  no 
premonitory  symptoms  of  any  kind ;  a  man  was  sitting 
smoking  and  talking,  and  fell  and  died  in  a  few  minutes. 
The  post  mortem  examination  showed  a  mass  of  hydatid 
cysts  embedded  in  the  wall  of  the  left  ventricle.  In  Mr. 
Price's  case  (1821),  a  boy,  ten  years  old,  fell  and  died 
in  a  few  minutes,  having  seemed  in  perfect  health  up 
to  the  time  of  his  death.  The  post  mortein  examination 
showed  a  large  hydatid  in  the  muscular  substance  of 
the  heart,  pericardial  adhesions,  and  about  two  ounces 
of  dark  fluid  in  the  pericardium. 

The  diagnosis  of  hydatid  disease  of  the  lung  or  of  the 

^Herbert  Evans,  "Case  in  which  a  cyst  containing  hydatids 
was  found  in  the  substance  of  the  heart."  "Med.  Chir.  Soc. 
Trans.,"  1832,  vol.  xvii.,  p.  507.  Another  case  is  recorded  in  the 
Society's  "Transactions"  for  1821. 

=  '  Hydatids  of  the  Heart,"  W.  H.  E.  Knaggs,  M.D..  "Lancet," 
Jan.  4th,  1896. 


4IO  SURGERY    OF    THE    CHEST. 

pleura  may  present  very  great  difificulties,  and  it  has  often 
been  mistaken  for  other  diseases,  e.g.,  pleural  effusion, 
bronchiectasis,  or  tubercular  cavity.  Or  hydatid  disease 
and  empyema  may  both  be  present  together.  The 
occurrence  of  haemoptysis  ^  at  an  early  period  in  the 
patient's  illness,  or  in  greater  quantity  than  one  would 
expect  in  other  diseased  conditions  presenting  similar 
physical  signs  and  symptoms,  may  perhaps  lead  the 
surgeon  to  the  right  diagnosis ;  and  the  sputa  must  be 
carefully  and  repeatedly  examined.  With  exploratory 
puncture,  we  come  to  consider  the  operation  for  this 
disease,  and  the  chances  of  recovery  without  operation.^ 

Neisser  (1887)  in  62  cases  of  hydatid  of  the  lung,  left 
without  operation,  found  as  follows  :  25  recovered,  or 
were  relieved,  after  the  cyst  had  opened  into  the  air- 
passages  ;  I  recovered,  after  it  had  opened  into  the 
bowel ;  23  died  without  either  natural  or  surgical  relief; 
12  died  in  spite  of  the  cyst  having  opened  into  the 
air-passages  ;  and  in  i  case,  death  followed  the  breaking 
of  it  into  a  vein.  He  puts  the  mortality  of  the  disease, 
left  to  itself,  at  587  per  cent. 

Madelung  (1885)  gives  a  more  favourable  view  of  the 
natural  end  of  these  cases.  Out  of  his  collection  of  19 
instances  of  hydatid  of  the  lung,  without  operation, 
10  recovered,  3  were  relieved,  after  the  cyst  had  opened 
into  the  bronchi,  and  6  died. 

Davaine  (1877)  agrees  with  Neisser:  two-thirds  of 
the  cases  left  to  themselves  end  in  death. 

Hearn  (1875)  collected  no   less  than    144  cases:  of 

'  Two  cases  of  profuse  fatal  haemoptysis  are  recorded  by  Dr. 
Curnow  and  Dr.  Percy  Kidd  ("  Path.  Soc.  Trans.,"  1883  and 
1S85).  It  is  especially  likely  to  follow  the  expectoration  of  large 
pieces  of  cyst-wall. 

""For  references,  see  RicheroUe,  "  Chirurgie  du  Poumon," 
Paris,  i8q2. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        411 

these,  62  recovered,  and  82  died.  Of  the  62  that  re- 
covered, 45  were  cured  by  bursting  of  the  cyst  into  the 
air-passages,  5  by  puncture,  and  12  by  incision. 

Lehmann  (1882)  gives  8  cases,  of  which  one,  and  one 
only,  recovered ;  and  this  one  recovery  was  due  to 
operation. 

It  is  plain  that  the  mortahty  of  hydatid  disease  of  the 
lung,  left  to  itself,  is  somewhere  between  50  and  60  per 
cent.,  to  say  nothing  of  the  years  of  illness  which  some 
of  these  patients  have  to  undergo. 

The  rupture  of  the  cyst  into  the  bronchi  may  of  itself 
be  a  frightful  ordeal,  even  if  it  does  not  end  in  death. 
Richerolle  quotes  the  case  of  a  man,  aged  22,  whose 
illness  began  in  October,  1888,  with  pleurisy  of  the  right 
side,  followed  by  effusion  which  was  absorbed.  In 
March,  1889,  the  effusion  recurred  and  was  again  ab- 
sorbed. In  April,  haemoptysis  set  in,  and  he  was  put 
under  treatment  for  tubercular  phthisis,  and  later  was 
sent  first  to  La  Bourboule  and  then  to  Algiers.  By 
December,  he  was  suffering  intense  dyspnoea,  constant 
cough,  and  profuse  blood-stained  expectoration,  and  was 
very  feeble.  On  Dec.  31st  he  coughed  up  nearly  a  pint 
of  watery  fluid ;  then  blood  came  with  it ;  then  pure 
blood.  He  coughed  up  in  this  way  3^^  pints  of  pure 
blood  ;  lost  consciousness,  and  remained  unconscious  for 
four  days.  Later,  he  suffered  violent  painful  attacks  of 
cough,  and  the  sputa  were  those  of  gangrene.  A  fort- 
night after  the  rupture  of  the  cyst,  he  coughed  up  a 
quantity  of  membranes,  and  then  began  to  improve.  A 
year  later,  he  was  in  good  health,  but  the  sputa  were 
still  purulent. 

The  statistics  of  operation  are  in  strong  contrast  with 
those  of  non-interference.  In  1885,  Thomas,  an 
Australian  surgeon,  collected  32  cases  of  hydatid  of  the 


412  SURGERY    OF    THE    CHEST. 

lung,  treated  by  free  incision,  with  no  less  than  25 
recoveries  ;  he  puts  the  mortality  of  the  disease,  left  to  it- 
self, at  54  per  cent. ;  treated  by  puncture,  at  27  ;  treated 
by  resection  and  incision,  at  16.  Lopez,  of  Lisbon, 
collected  36  cases,  of  which  no  less  than  31  were  cured 
by  surgical  intervention. 

Licision,  not  puncture  :  the  results  of  simple  puncture 
or  aspiration  are  very  bad.  Maydl  (1891)  collected  16 
cases  treated  by  simple  puncture  ;  of  these,  no  less  than 
eleven  died,  or  69  per  cent. ;  five  of  them  died  of  puru- 
lent pleurisy  or  of  pyo-pneumothorax  ;  six  directly  of  the 
puncture,  within  a  few  hours  or  even  a  few  minutes. 

The  following  cases  illustrate  the  disastrous  results 
that  may  come  of  simple  puncture  or  aspiration  of  a 
hydatid  cyst  of  the  lung  1 : — 

1.  A  man,  between  50  and  60  years  old,  was  admitted  to 
the  Prince  Alfred  Hospital,  Sydney,  with  great  shortness  of 
breath,  and  the  case  was  correctly  diagnosed  as  one  of 
hydatid  of  the  right  lung.  An  aspirating  trochar  was  passed 
inward  in  the  axillary  Hne  at  the  level  of  the  nipple  ;  a  few 
ounces  of  clear  fluid  ran  into  the  bottle  ;  a  gush  of  clear 
hydatid  fluid  came  from  his  mouth,  he  fell  back,  and  died  in 
a  few  minutes.  Pos/  7;tor/em,  nearly  the  whole  of  the  right 
side  of  the  chest  was  filled  by  a  hydatid  cyst  ;  and  tlie  oppo- 
site lung  had  been  swamped  by  the  fluid  running  out  by  the 
side  of  the  trochar,  and  so  up  the  right  bronchus  and  down 
into  the  left  lung. 

2.  A  boy,  9  years  old,  was  admitted  to  Hospital  after  a 
fortnight's  illness,  with  signs  as  of  pleural  efl"usion  on  the  left 
side.  A  large  aspirating  needle  was  put  in  just  below 
the  angle  of  the  scapula,  and  a  few  drachms  of  clear  watery 
fluid  escaped  through  the  needle  as  the  aspirating-bottle  was 
being  adjusted  to  it.  But  when  the  stopcock  was  turned,  no 
fluid  ran  into  the  bottle  ;  clear  frothy  fluid  began  to  pour  out 
of  the  boy's  mouth,  three  or  four  ounces  in  a  few  seconds. 

'  For  references,  see  "  St.  Bart.  Hosp.  Rep.,"  1892,  vol.  xxviii., 
p.  238;  'Clin.  Soc.  Trans.,"  1891,  vol.  xxiv.,  p.  73;  Ricber- 
olle,  loc.  cit.  ;  and  Heydweiller,  "  Ueber  Lungen-chirurgie," 
Berlin,  1894. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        413 

His  breathing  became  difficult,  his  lips  blue,  and  his  pulse 
feeble ;  he  became  restless,  and  distressed,  emphysema  ran  all 
over  the  side  and  the  neck,  and  he  died  in  a  few  minutes. 
Post  jnortetn.,  in  the  lung  was  a  collapsed  cavity,  a  little 
smaller  than  one's  fist,  containing  a  single  collapsed  hydatid 
cyst  ;  a  main  bronchus  opened  by  several  perforations  into 
the  cavity,  and  the  lower  lobe  of  the  lung  was  collapsed 
and  airless. 

3.  A  man,  aged  26,  after  a  month's  illness  (dyspnoea, 
localized  pain  in  the  lower  part  of  the  right  side)  presented 
signs  of  hydatid  disease  of  the  right  lung.  An  exploratory 
puncture  was  made  ;  two  hours  later,  he  sank  and  died. 
Posl  mortem.,  there  was  found  a  hydatid  cyst,  of  a  capacity  of 
Af\  pints,  between  the  lobes  of  the  right  lung  ;  a  large 
bronchus  opened  into  it. 

4.  A  young  man,  aged  19,  after  two  years'  illness  (cough, 
shortness  of  breath,  evening  rise  of  temperature)  presented 
signs  of  hydatid  disease  of  the  right  side  of  the  chest  ;  and 
the  diagnosis  was  made  certain  by  exploratory  puncture. 
Aspiration  was  then  made  through  the  fifth  space,  and  36 
ounces  of  fluid  were  withdrawn.  This  was  followed  by 
sudden  distress  and  oppression,  paroxysmal  cough,  and 
expectoration  of  serous  fluid,  which  was  found  to  contain 
booklets.  Later,  he  became  feverish,  and  the  sputa  became 
purulent.      Nineteen   days    after  aspiration,   the   cyst   was 

.incised,  and  great  quantities  of  fluid,  membranes,  and  pus 
were  let  out  ;  irrigation  of  the  pleura  caused  coughing  and 
choking  and  a  taste  of  the  lotion  in  his  mouth.  Syphon- 
drainage  was  employed  ;  in  three  months  the  lung  had 
expanded,  and  only  a  fistula  remained,  which  closed  four 
months  later. 

Disasters  of  this  kind  are  not  very  uncommon,  accord- 
ing to  Thomas, ^  in  cases  where  a  living  hydatid  of  the 
lung  has  been  treated  by  puncture.  It  is  not  impossible 
that  some  of  them  may  be  instances  of  serous  oedema  of 
the  lung,  with  profuse  albuminous  expectoration,  such  as 
may  follow  (Chap,  xiv.)  the  withdrawal  of  a  pleural 
effusion  ;  but  in  the  cases  that  I  have  quoted  it  is  evident 
that  what  happened  was  not  this,  but  escape  of  the 
hydatid   fluid   into   the   air-passages.     As    Dr.  Bristowe 

'  "  Australian  Medical  Journal,"  1889. 


414         SURGERY    OF    THE    CHEST. 

has  shown,  the  living  hydatid  just  fills  the  cavity  in 
the  lung,  and  the  walls  of  this  cavity  are  like  a  sieve. 
So  soon  as  the  hydatid  is  punctured  or  ruptured,  air 
passes  from  the  lung  into  the  cavity,  and  hydatid  fluid 
passes  from  the  cavity  into  the  lung. 

The  fear  of  this  is  not  the  only  fault  of  the  treatment 
by  puncture  or  aspiration. 

'  I  have  knowledge  of  at  least  two  cases,  in  which  death 
very  speedily  followed  simple  puncture  and  aspiration  of 
hydatid  cyst,  apparently  from  shock.  The  result  in  almost 
every  instance  is  a  failure.  The  cannula  becomes  choked 
immediately  by  part  of  the  mother-sac,  or  the  numerous 
daughter-cysts,  and  hardly  more  than  a  few  drachms  of  fluid 
are  withdrawn.  The  trochar  probably  enters  a  daughter- 
cyst,  and  this,  having  emptied  itself,  forthwith  collapses  and 
envelops  the  cannula  ;  a  fresh  puncture  has  to  be  made, 
and  the  same  result  ensues.  Blood  may  be  caused  to  exude 
into  the  sac,  and  thus  considerable  harm  may  follow.'^ 

'Apart  from  the  immediate  dangers  of  puncturing  the 
cyst,  there  is  yet  another  drawback  to  this  method  of  treat- 
ment. Once  you  have  emptied  it,  its  walls  collapse,  and  you 
will  have  a  difficulty  in  finding"  your  way  into  it  if  operation 
becomes  necessary.'  - 

And  there  is  also  the  risk  of  hydatid  fluid  leaking  into 
the  pleura,  and  setting  up  violent  inflammation  of  it. 
The  treatment  of  hydatid  disease  of  the  lung  is  the  same 
as  that  of  other  collections  of  fluid  in  it.  Exploratory 
puncture,  with  a  very  fine  needle,  must,  if  it  give  sure 
evidence  of  the  disease,  be  followed  at  once  by  an  opera- 
tion on  the  same  lines  as  the  operation  for  any  other 
cavity  in  the  lung. 

Aspergillus. 

The  lungs  may  be  infected  by  vegetable  parasites, 
as  well  as  by  those  that  belong  to  the  animal  kingdom. 

'Sir  Dyce  Duckworth,  "  St.  Bart.  Hosp.  Rep.,"  1879,  vol.  xv., 
p.  28. 

-  Ileydenreich,  "  Semaine  Med.,"   1891. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        415 

Freyhau^  has  recorded  a  case  of  this  sort  of  'pneumo- 
mycosis '  in  a  man,  aged  22.  He  was  at  first  thought  to 
be  suffering  from  pneumonia  due  to  emboHsm.  There 
was  pleural  effusion,  of  a  hemorrhagic  character ;  a  fort- 
night later,  he  began  to  expectorate  clumps  of  a  mycotic 
growth — mycelium  with  conidia — and  this  continued  for 
many  weeks  ;  the  opposite  lung  also  became  infected. 
Freyhau  points  out  that  this  form  of  infection  can  only 
occur  in  a  lung  that  is  weakened  by  some  past  disease, 
e.g.,  by  an  old  hsemorrhage  into  its  substance.  It  was 
noted  that  the  masses  of  the  fungoid  growth  had  the 
smell  of  fresh  yeast. 

Dr.  Wheaton  has  published  a  case  of  a  child,  only  2i 
years  old,  who  died  of  phthisis  :  not  only  the  lung  but 
the  bronchi  and  the  tongue  were  invaded  with  patches 
and  masses  of  aspergillus. 

A  full  account  of  the  presence  of  these  vegetable 
moulds  in  the  air-sacs  of  birds  is  given  by  Mr.  Bland 
Sutton,  in  the  "Trans,  of  the  Path.  Society"  for  1885. 

Dr.  Percy  Kidd  has  shown  that  injection  of  the  spores 
of  aspergillus  into  the  auricular  vein  of  a  rabbit  produces 
an  abundant  growth  of  mycelium  in  various  organ?, 
especially  in  the  kidneys  ("  Path.  Soc.  Trans.,"  t886). 

Prof.  Boyce"  has  described  and  figured  a  specimen  of 
this  disease.  The  apex  of  the  lung  showed  a  few  small 
irregular  cavities,  in  which  were  scattered  white  bodies, 
about  the  size  of  pins'  heads  :  these  had  been  mistaken 
for  points  of  calcification.  The  history  of  the  specimen 
was  imperfect ;  the  patient  had  died  of  heart  disease  ;  no 
marked  lung  troubles  had  been  noted.      '  The  fungus  is 

'"Wien.  Med.  Presse,"  1892,  p.  185. 

^Remarks  upon  a  Case  of  Aspergillar  Pneumomycosis,  "  Journ. 
Path.  Bact.,"  Oct.  1892.  For  Dr.  Wheaton's  case,  see  "Path. 
Soc.  Trans.,"  1890.     Virchow  first  noted  the  disease  in  1856. 


4i6         SURGERY    OF    THE    CHEST. 

usually  regarded  as  a  secondary  phenomenon,  complica- 
ting an  ulcerated  or  gangrenous  condition  of  the  lung ; 
and  undoubtedly  the  aspergilli,  in  man  at  least,  are  not 
severely  pathogenic.  I  know  of  no  case  occurring  of 
general  infection  in  man.' 

In  1876,  FUrbringer^  put  together  eleven  instances 
where  mycotic  elements  were  present  in  the  lung-tissue  ; 
in  most  of  the  cases  they  were  not  observed  in  the  sputa, 
but  were  only  found  J>os^  vwrtem.  He  points  out  that 
their  growth  is  always  secondary  to  some  grave  disease  of 
the  lung  :  nearly  always  (nine  times  out  of  eleven)  to  the 
breaking-down  of  a  hsemorrhagic  infarct  or  of  an  old 
haemorrhage  in  the  lung-tissue.  It  is  stagnant  disin- 
tegrated blood  that  suits  these  fungoid  moulds.  They  are 
not  found  in  acute  pulmonary  diseases,  nor  in  ordinary 
acute  gangrene  of  the  lung;  the  latter  condition  is  the 
work  of  the  organisms  of  putrefaction,  but  is  not  favour- 
able to  mycotic  growth.  There  is  no  evidence  that  their 
presence  is  in  itself  dangerous  to  life. 

Actinomycosis. 

Actinomycosis  is  a  far  more  important  infection,  and 
must  be  very  carefully  considered.  We  are  not  here 
concerned  with  the  life -history  of  the  fungus,  or  with  the 
microscopic  characters  of  its  different  forms,  but  only 
with  the  clinical  signs  of  its  presence  in  the  lungs  or  the 
pleurae.  The  story  of  the  discovery  of  the  disease 
is  of  very  great  interest.  Langenbeck  in  1845,  M^- 
Thomas  Smith-  in   1855,   and   Lebert  in   1857,   found 

'  '  Beobachtungen  iiber  Lungenmycose  beim  Menschen," 
"  Virchow's  Arch.,"  1876,  p.  330.  A  specimen  of  the  growth  has 
just  lately  (May  5,  1896)  been  shown  at  the  Pathological  Society. 

*' A  Fading  Record :  Early  Observations  on  the  Ray-Fungus, 
by  Mr.  Thomas  Smith.'  Dr.  Kanthack,  "St.  Bart.  Hosp. 
Journal,"  Jan.  1896. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        417 

the  ray-fungus,  and  most  carefully  noted  and  drew 
it,  but  could  not  explain  the  nature  of  it. 
Bollingsr,  in  1877,  recognized  it  in  the  tissues  of 
animals,  in  the  swellings  of"  the  tongues  and  jaw- 
bones of  cattle;  the  disease,  "wooden  tongue,"  had 
long  been  known  to  veterinary  surgeons.  In  1882, 
Johne  succeeded  in  inoculating  animals  with  the  fungus, 
and  in.  1885  Israel  inocubted  a  rabbit  from  a  case  of  the 
disease  in  man  ;  a  year  later  Bostrom  reported  that  he 
had  succeeded  in  making  cultures  of  it.  The  first  case 
in  England  of  actinomycosis  of  the  hver  was  published  in 
1885.  The  first  case  of  the  disease  in  the  lung,  diagnosed 
during  the  patient's  life,  was  communicated  to  the 
Medico-Chirurgical  Society  on  Feb.  12th,  1889,  by 
Dr.  Douglas  Powell  and  Mr.  Godlee — a  landmark  in  the 
advance  of  our  art. 

Israel^  (1877)  collected  38  cases,  and  divided  them 
according  to  the  way  in  which  infection  took  place.  In 
17,  the  mouth  or  the  pharynx  was  attacked;  in  9,  the 
air-passages  or  the  lungs  ;  and  in  7,  some  part  of  the 
alimentary  system.  In  5,  the  way  of  infection  was  not 
clearly  made  out. 

The  way  by  which  the  fungus  reaches  the  lung  or  the 
pleura  may  in  this  or  that  case  be  hard  to  trace.  Israel 
believed  that  he  found  the  ray-fungus  in  the  cavity  of  a 
decayed  tooth,  and  he  has  recorded  a  case  where  actino- 
mycosis of  the  lung  followed  the  slipping  of  a  bit  of 
tooth  into  the  air-passages.  Partsch-  has  described  and 
figured  the  root  of  a  bicuspid  tooth,  from  a  patient  who 


'  For  the  whole  subject,  see  Mr.  Shattock's  paper  in  the  "Path. 
Soc.  Trans.,"  1885. 

^  Partsch,    "  Die    Eingangspforte  des  Aktinomyces,"    "  Wien. 
Med.  Wchnschr.,"  1893,  p.  97;  Delepine,  "Trans.  Path.  Soc," 
See  also  "  Lancet,"  Nov.  30th,  1889. 

27 


4i8  SURGERY    OF    THE    CHEST. 

had  actinomycosis  of  the  lower  jaw,  showing  two  ray- 
fungi  lying  just  inside  the  lower  end  of  the  pulp-cavity. 
But  Delepine  has  several  times  found  an  organism  in  the 
tartar  encrusting  the  teeth,  and  in  the  crypts  of  the 
tonsils,  closely  resembling  the  ray-fungus,  but  only  the 
common  leptothrix  buccalis,  held  together  by  calcareous 
salts.  '  Lately  one  of  my  own  friends  brought  me  a 
specimen  of  this  organism,  removed  from  his  own  mouth — 
a  thing  which  naturally  filled  him  with  anything  but 
pleasant  feelings,  for  he  knew  all  about  the  parasite — I 
was,  however,  able  to  comfort  him  very  rapidly.'  A 
curious  case  of  infection  occurred  some  few  years  ago, 
in  an  inspector  of  imported  cattle.  He  had  sometimes 
to  look  through  hundreds  of  papers  relating  to  their  con- 
signment, and  used  to  turn  over  the  sheets  moistening 
his  finger  on  his  tongue.  Some  of  the  cattle  being 
infected,  his  lower  jaw  was  attacked  by  the  disease.  It 
is  possible  that  actinomycosis,  like  aspergillus,  can 
flourish  only  in  a  lung  that  is  weak  or  predisposed  to 
infection. 

The  fungus,  having  reached  the  lung,  tends  to  make 
its  way  toward  the  surface  of  it,  and  to  infect  the  pleural 
cavity.  The  case  may  thus  present  itself  to  the  surgeon 
as  a  case  of  empyema.  Or  the  case  during  life,  or  the 
specimen  after  death,  may  be  mistaken  either  for  tuber- 
cular disease  or  for  sarcoma.  Careful  examination  of  the 
sputa  may  give  positive  results.  Heusser  of  Davos,i  in 
a  female  patient  sent  out  there  as  a  case  of  phthisis, 
found  in  the  sputa  no  tubercle-bacilli,  but  well-marked 
granules  of  actinomycosis.  The  illness  ran  just  the  same 
course  as  tubercular  phthisis  with  formation  of  cavities, 
and  she  showed  marked  improvement  during  her  stay  at 
Uavos. 

1  "  Miinchen,  Med.  Wchnschr.,"  1895,  p.  49. 


INTRATHORACIC    NEW    GROWTHS,    ETC.        419 

There  is  some  reason  to  believe  that  actinomycosis  of 
the  lung  is  not  necessarily  fatal.  Schlange^  gives  three 
cases  where  he  was  able  to  speak  with  some  certainty  on 
this  point.  'In  one  of  them,  a  boy  13  years  old,  the 
disease  led  to  multiple  perforations  of  the  right  side  of 
the  chest,  so  that  the  case  seems  hopeless.  The  other 
two,  who  have  suffered  for  five  or  six  years  with  actino- 
mycosis of  the  lung,  have  now  for  some  time  had  no 
granules  in  their  sputa,  and  their  general  condition  is 
decidedly  improved.' 

We  cannot  expect  much  good  from  drugs,  but  iodide 
of  potassium  is  said  to  be  of  some  use  ;  and  Dr.  Poore^ 
has  just  published  a  case  of  actinomycosis  of  the  right 
pleura,  drawing  attention  to  Raullin's  observation  that 
aspergillus  niger — the  fungus  that  one  sometimes  finds  in 
the  auditory  meatus — will  not  grow  in  a  nutrient  fluid 
containing  even  the  faintest  trace,  one  part  in  a  million 
and  a  half,  of  silver  nitrate,  and  will  not  grow  in  a  silver 
bowl.  He  suggests,  therefore,  that  the  use  of  silver 
nitrate,  both  as  a  lotion  and  internally,  may  avail  to  check 
the  growth  of  the  fungus  of  actinomycosis. 

Richerolle   (1892)   gives   the  following   collection    of 

cases  :  a  careful  study  of  them  will  show  the  different 

conditions  of  the  disease  which  go  in  favour  of  operation 

or  against  it.^ 

I.  A  farm-labourer,  aged  29,  after  a  year's  illness  (slight 
jaundice,  pains  over  lower  right  ribs,  cough,  no  hasmoptysis, 
latterly  swelling  at  the  seat  of  the  pains),  was  admitted  to 
Hospital.  There  was  retraction  of  the  right  side  of  the 
chest  ;  dulness  up  to  the  fifth  rib,  with  loss  of  breath-sounds 

1 "  Zur  Prognose  der  Aktinomycose,"  "  Deutsch.  Gas.  f.  Chir.," 
1892. 

=  "  Clinical  Journal,"  April  22nd,  1896. 

3  An  interesting  case  of  actinomycosis  of  the  wall  of  the  chest 
has  lately  been  published  by  Sir  Dyce  Duckworth  ("  St.  Bart 
Hosp.  Reports,"  1895). 


420  SURGERY    OF    THE    CHEST. 

and  of  vocal  vibrations;  no  rales;  no  fever;  induiation  of 
tissues  between  nipple-line  and  anterior  axillary  line.  The 
diagnosis  was  caries  of  the  ribs  with  secondary  pleurisy. 
Puncture  let  out  more  than  a  pint  of  greenish  fluid.  The 
swelling  increased,  the  indurated  tissues  broke  down  with 
numerous  small  fistulas,  and  blood-stained  fluid  escaped,  with 
small  granules  like  lycopodium  seeds,  which  the  microscope 
showed  to  be  actinomycotic.  The  sputa  to  the  naked  eye 
were  indistinguishable  from  those  of  slight  chronic  bron- 
chitis, but  were  shown  by  the  microscope  to  contain  mycelial 
filaments.  The  swelling  was  now  freely  opened  and  the 
diseased  skin  removed  ;  but  abscesses,  containing  the  fun- 
gus, came  over  all  parts  of  the  body,  and  the  patient  died, 
exhausted,  of  failure  of  the  heart,  three  years  alter  the  onset 
of  the  disease.  The  pos^  mortem  examination  showed  sub- 
cutaneous and  inti  a-muscular  actinomycotic  abscesses  of  the 
head,  trunk,  and  limbs  ;  the  disease  had  also  infected  the 
heart  and  the  pericardium,  the  spine,  the  jejunum,  and  the 
riglit  testicle.  Both  lungs  were  affected^  the  right  pleura, 
and  the  intercostal  muscles.  The  disease  had  begun  in  the 
lower  lobe  of  the  right  lung. 

2.  The  details  of  this  case  are  not  given.  Both  the  club- 
shaped  forms  and  the  filaments  of  the  disease  were  found  in 
the  sputa.  Post  mo7-te»i,  in  the  base  of  the  right  lung,  was 
a  huge  abscess  cavity,  the  size  of  an  orange,  single,  circum- 
scribed :  the  pus  in  it  was  found  to  contain  the  fungus.  The 
abscess  could  easily  have  been  reached  by  operation. 

3.  A  woman,  aged  40,  employed  in  a  silk-factory,  was 
admitted  to  Hospital  in  March,  1888,  after  several  months' 
illness  (cough,  haemoptysis,  shivering  fits,  evening  rise  of 
temperature,  night-sweats).  Over  the  right  apex,  the  breath- 
sounds  were  harsh,  and  a  friction-sound  was  heard  ;  the 
heart-beat  was  in  the  third  space  ;  cough,  fever,  thirst, 
diarrhoea.  A  iew  days  later,  pericardial  friction-sounds  were 
heard  ;  signs  of  thrombosis  of  the  deep  veins  followed,  and 
she  died  early  in  April.  The  post  mortem  examination 
showed  purulent  pericarditis,  with  abscess  of  the  wall  of  the 
right  ventricle  containing  actinomycotic  granules ;  infiltration 
of  the  border  of  the  left  lung  with  the  disease  ;  and  a  small 
mass  of  it  in  the  right  pleura,  beneath  the  ninth  and  tenth 
ribs. 

4.  A  boy,  14  years  old,  was  admitted  to  Hospital  in 
March,  1885,  after  a  year's  illness  (shiverings,  loss  of  flesh, 
haemoptysis,  swelling  over  the  right  side  of  the  chest,  high 
up  and  far  back  toward  the  spine).     On  admission,  he  was 


INTRATHORACIC    NEW    GROWTHS,    ETC.        421 

anaemic,  dusky,  short  of  breath.  In  the  right  interscapular 
region  was  a  hard  dense  swelhng,  without  fluctuation. 
There  was  a  smaller  swelling  lower  down,  on  the  oppo- 
site side  of  the  chest,  near  the  spine.  Total  absence  of 
sounds  over  the  whole  of  the  right  lung;  slight  cough,  with 
catarrhal  sputa;  liver  below  ribs,  spleen  enlarged,  cedema 
over  malleoli,  much  albumen  in  urine,  temp.  ioo"4'.  Ex- 
ploratory puncture  drew  only  blood.  The  sputa  were  very 
carefully  examined,  but  showed  neither  tubercle  bacilli  nor 
actinomycotic  forms.  He  died  a  month  after  admission. 
Post  viorievi,  sero-purulent  effusion  in  the  peritoneal  cavity. 
The  right  lung  was  everywhere  adherent.  The  disease  was 
diffused  throughout  the  right  pleura,  and  had  invaded  the 
posterior  mediastinum,  the  diaphragm,  and  the  front  of  the 
spine.  The  left  lung,  not  adherent,  showed  false  mem- 
branes, and  soft,  reddish-gray  granulations,  over  its  lower 
lobe. 

5.  A  woman,  50  years  old,  suffering  with  cough,  noted  a 
painful  purplish  swelling  to  the  inner  side  of  the  right  breast. 
Later,  it  fluctuated,  broke  down  at  several  points,  and  dis- 
charged a  large  quantity  of  pus.  Actinomycotic  forms  were 
found  both  in  the  discharge  and  in  the  sputa.  The  breast 
was  removed,  but  this  did  not  stop  the  advance  of  the 
disease.  The  post  viorte/n  examination  showed  that  it  had 
begun  in  the  right  lung,  and  spread  thence  into  the  anterior 
mediastinum  and  the  iDreast. 

One  only  of  these  five  cases  was  likely  to  receive  much 
benefit  from  surgery.  Still,  the  disease  sometimes  pre- 
sents signs  less  unfavourable  for  surgical  interference. 
It  may  be  not  diffuse  and  multiple,  but  single  and 
circumscribed.  The  surgeon  may,  under  these  circum- 
stances, save  life,  or  may  at  least  prolong  it,  and  improve 
the  general  condition  of  the  patient. 


422 


CHAPTER   XXVII. 

SUBPHRENIC  ABSCESS.     OPERATION  THROUGH  THE 
PLEURA  FOR  HYDATID  CYST  OF  THE  LIVER. 

We  have  in  this  last  chapter  to  note  two  diseases  that 
begin  outside  the  chest,  but  may,  as  they  advance,  infect 
or  invade  it :  suppuration  starting  beneath  the  diaphragm 
and  subsequently  invading  the  pleura,  and  hydatid  cyst 
of  the  liver  pushing  upvvard  into  the  chest.  Of  both  these 
disorders  many  cases  have  of  late  years  been  recorded, 
which  are  full  of  interest. 

Subphrenic  Abscess. 

The  history  of  the  exact  diagnosis  and  treatment  of 
this  disease  begins  with  a  case  published,  in  1845  ^  by 
Dr.  Barlow  and  Dr.  Wilks  :  it  was  an  example  of  sub- 
phrenic abscess  of  the  left  side,  containing  gas  as  well  as 
pus,  due  to  perforation  of  the  stomach.  It  had  caused 
inflammation  of  the  left  pleura,  with  sero-purulent 
effusion,  but  there  was  no  actual  perforation  of  the 
diaphragm.  The  physical  signs  closely  imitated  those  of 
pyo-pneumothorax  ;  but  careful  examination  showed  that 
the  collection  of  gas  lay  de/ow  the  level  of  the  pleural 
effusion.  There  was  no  history  of  any  disease  of  the 
lungs  such  as  would  be  likely  to  cause  pyo-pneumothorax; 
it  was  hard  to  see  how  there  could  be  two  distinct 
effusions  in  the  pleura,  one  above,  of  fluid  only,  and  one 
below,   of  fluid  and  gas  together  ;  and  the  site  of  the 

•  "  London  Medical  Gazette,"  May,  1845. 


SUBPHRENIC    ABSCESS.  423 

most  marked  resonance  was  beneath  the  false  ribs.  For 
these  reasons,  the  case  was  rightly  diagnosed  as  one 
of  subphrenic  abscess.^  From  about  this  time  onward, 
many  isolated  examples  of  the  disease  were  published  ; 
and  monographs  on  it  were  written  by  Leyden  (1880) 
and  Tillmann  (1882).  In  England,  beside  a  number  of 
records  of  separate  cases,  we  have  the  very  valuable 
work  of  Dr.  Penrose  and  Dr.  Lee  Dickinson  ^  (1893), 
Dr.  Coupland,  Dr.  Hector  Mackenzie,  and  Mr.  Gilbert 
Barling^ ;  and  in  1894,  Maydl's  book^  was  published, 
which  swept  into  its  net  every  case  that  had  hitherto 
been  recorded. 

Maydl,  dealing  with  a  collection  of  no  less  than  179 
cases,  divides  them  according  to  their  causes.  The 
stomach  or  the  duodenum  started  the  suppuration  in  35 
cases  ;  the  ctecum  or  the  appendix,  in  25  ;  the  liver  or  the 
biliary  passages,  in  20;  internal  injuries,  in  18;  hydatid 
disease,  in  17;  the  intestines,  in  13.  There  were  11 
cases  of  '  metastatic  '  subphrenic  abscess  :  1 1  followed 
inflammation  round  the  kidney;  and  11  were  'miscel- 
laneous.'     Disease  inside  the   chest  was  the  cause  of 

1 '  Our  admiration  at  the  acuteness  of  this  diagnosis  must  be 
mixed  with  some  astonishment  that  even  now,  forty  years  later — 
in  spite  of  the  warning  given  by  this  case  not  to  confound  a  pyo- 
pneumothorax with  a  subphrenic  abscess  containing  air — some 
of  the  signs  of  the  latter  disease,  as  Barlow  described  them,  are 
either  neglected,  or  not  formulated  so  sharply  and  accurately  as 
they  were  by  him.  His  short  and  pregnant  notes  on  the  case 
contain  all  that  is  essential  in  the  whole  series  of  accepted 
modern  views  as  to  the  causes  and  diagnosis  of  subphrenic 
abscess.'     Maydl,  p.  7. 

^  "  Cases  of  Abscess  beneath  the  Diaphragm  in  connection  with 
Perforating  Gastric  Ulcer."  "  Clin.  Soc.  Trans.,"  1893,  vol.  xxvi., 
p.  72. 

3"  Gastric  Perforation,"  etc.,  "  Ingleby  Lectures,"  1895. 

■*  "  Ueber  Subphrenische  Abscesse. "  Wien,  1894,357  pages. 
Since  Maydl's  book,  there  is  an  excellent  essay,  with  many 
diagrams,  by  Sachs,  "Arch.  f.  Klin.  Chir.,"  1895,  vol.  1.,  p.  16. 


Number  of  Cases 

Total  Number 

where  Air  or  Gas 

of  Cases. 

was  in  the  Abscess 

cavity. 

35 

20 

25 

8 

20 

I 

18 

3 

17 

3 

13 

4 

II 

I 

II 

I 

II 

5 

9 

I 

6 

0 

424  SURGERY    OF    THE    CHEST. 

subphrenic  abscess  in  9  cases  ;  external  injuries  in  6  ; 
and  caries  of  the  ribs  in  3. 

To  the  question,  how  often  these  subphrenic  abscesses 
contain  air  or  gas  as  well  as  pus,  he  replies  that  it 
depends  chiefly  on  the  primary  cause  of  the  abscess. 

Starting- Point  of 
the  Abscess. 

Stomach  or  Duodenum 

Caecum  or.  Appendix 

Liver  or  Biliary  Passages 

Internal  Injuries 

Hydatid  Disease 

Intestines 

'  Metastatic  '    . . 

Perinephritis 

'Miscellaneous' 

Disease  inside  the  Chest 

External  Injuries 

Caries  of  the  Ribs         . .  3  . .  o 

To  indicate  the  difference  in  physical  signs  between  a 
pyo-pneumothorax  and  a  subphrenic  abscess  containing 
gas,  he  gives  two  diagrams  {Plate  XII.);  and  a 
good  commentary  on  them  is  to  be  found  in  what  Dr. 
Coupland  and  Mr.  Barling  have  lately  written  about  the 
diagnosis  of  these  cases.  In  addition  to  the  general  signs 
of  pus-formation,  local  signs  present  themselves  :  a  swel- 
ling, or  at  all  events  a  fulness,  in  the  epigastrium.  The 
physical  signs  are  those  of  pneumothorax,  but  they  are  in 
a  different  position  from  that  which  pneumothorax  occu- 
pies. There  is  hyper-resonance  at  the  upper  part  of  the 
abdomen,  extending  somewhat  up  to  the  thorax;  but  not 
to  its  summit,  where  the  physical  signs  may  be  normal. 
The  tympanitic  resonance  may  extend  upward  behind  the 
sternum  to  a  remarkable  degree,  perhaps  into  the  axilla 
and  posteriorly  also.  With  this  resonance  there  may 
be  amphoric  breathing,  and  a  bell-sound  may  be  obtain- 
able.    The  heart  undergoes  displacement  to  some  extent, 


E.y 


0-2 


I-  o 


-J 


is 


k<  =  j: 


SUBPHRENIC    ABSCESS.  425 

but  not  to  the  degree  that  it  does  in  pneumothorax. 
With  this  tympanitic  resonance  in  front,  evidence  arises 
of  pleurisy  or  of  lung  consolidation.  1 

It  is  important  to  bear  in  mind  the  extraordinary 
number  of  different  causes  that  may  lead  to  subphrenic 
abscess.  Lampe  -  last  year  published  seven  cases  :  two 
from  gastric  ulcer,  two  from  ulceration  or  gangrene  of 
the  vermifo.m  appendix,  one  from  internal  injury,  one 
after  curetting  of  the  uterus,  and  one  from  empyema. 

With  so  many  possible  causes,  subphrenic  abscess  can 
hardly  be  a  rare  disease  ;  and  Dr.  Penrose  and  Dr.  Lee 
Dickinson  found  that  ten  cases  (all  from  gastric  ulcer) 

'  Dr.  Sidney  Coupland,  "  Subphrenic  Abscess  simulating 
Pneumothorax."     "Brit.  Med.  Journ.,"  March  23rd,  1889. 

^  "  Miinchen.  Med.  Wchnschr.,"  May  14th,  1895.  An  abstract 
of  the  cases  is  given  in  the  "  Brit.  Med.  Journ.,"  July  6th,  1895. 
(i)  A  man,  2  >  years  old  :  rupture  of  gastric  ulcer  on  posterior 
wall  of  stomach,  near  pylorus;  suppurative  peritonitis;  opera- 
tion ;  death.  (2)  A  man,  25  years  old  :  gastric  ulcer  near  greater 
curvature  :  pain  in  the  epigastrium  and  vomiting,  four  and  a  half 
weeks  previously  ;  operation  ;  death.  (3)  A  man,  38  years  old  : 
had  long  suffered  from  constipation;  illness  began  w'th  abdomi- 
nal pain  and  fever  ;  later,  jaundice,  and  pain  in  region  of  liver. 
Was  already  dying  when  admitted  to  Hospital  ;  no  operation. 
Post  jnoiievi,  gangrene  of  vermiform  appendix.  The  inflammation 
had  extended  upward  behind  the  caecum,  kidney,  and  liver,  to  the 
subphrenic  region  on  the  ri.ht  side.  (4)  A  boy,  aged  14; 
perforation  of  appendix,  perityphlitic  abscess,  suppurative 
phlebitis,  hepatic  abscess ;  operation;  death.  {-)  A  man,  aged 
30  :  the  disease  followed  a  blow  ;  operation  :  after  a  very  severe 
illness,  was  on  the  way  to  recovery  at  the  time  his  case  was  pub- 
lished. (6)  A  woman,  aged  3=:  curetting  of  the  uterus  on  the 
second  day  of  an  incomplete  abortion  ;  pain  in  upper  part  of 
abdomen  began  on  seventh  day ;  operation ;  recovery.  (7)  A 
man,  22  years  old :  after  pneumonia,  empyema,  which  opened 
into  the  air-passages.  For  a  time,  he  improved  ;  then  came 
pain  in  the  lower  part  of  the  chest,  and  in  the  abdomen.  Opera- 
tion showed  a  perforation  of  the  diaphragm  ;  recovery.  Thus, 
of  the  7  cases,  3  recovered  after  operation,  3  died  after  it,  and  i 
died  without  it.  In  none  of  them  was  there  gas  in  the  abscess- 
f^avitv.  In  three  of  them,  there  was  a  serous  effusion  in  the 
pleura. 


426  SURGERY    OF    THE    CHEST. 

were  recorded  at  St.  George's  Hospital  in  little  more  than 
four  years  (Dec.  1887  to  March,  1892). 

It  is  strange  that  so  many  cases  of  subphrenic  abscess 
should  be  due  to  disease  of  the  vermiform  appendix. 
According  as  the  suppuration  round  the  appendix  is 
inside  or  outside  the  peritoneal  cavity,  so  its  extension 
upward  to  the  subphrenic  region  is  intra-  or  extra- 
peritoneal. 1  Out  of  Maydl's  25  cases,  1 1  were  left  with- 
out operation  :  9  died  and  2  recovered.  Of  the  14  who 
received  operation,  no  less  than  9  were  saved.  In  one 
or  two  of  the  cases  the  caecum  was  at  fault  (ulceration, 
perforation  with  fish-bone)  not  the  appendix.  The  time 
that  elapsed  between  the  onset  of  the  perityphlitis  and 
the  plain  signs  of  subphrenic  abscess,  was  in  one  case 
only  three  days;  in  five,  it  was  less  than  three  weeks;  in 
five,  between  three  and  six  weeks  ;  in  one,  eight  weeks. 
Careful  analysis  of  the  25  cases  shows  that  in  every  case 
left  without  operation,  the  diaphragm  sooner  or  later  was 
perforated;  but  of  the  14  who  had  an  operation,  perfo- 
ration was  found  in  2  only ;  and  in  several,  the  signs 
of  a  pleural  effusion,  well  marked  before  the  operation, 
disappeared  after  it. 

The  following  case,  from  Hofmokl,  is  a  good  picture 
of  this  form  of  subphrenic  abscess  :  — 

A  boy,  16  years  old,  was  attacked  on  Sept.  25th  with 
acute  perityphlitis  (fever,  shivering,  vomiting,  swelling  in 
right  iliac  fossa).  Sept.  30th,  pain  and  fulness  in  the 
right  hy  ochondrium  ;    physical  signs   of  displacement 

'  The  question  arises,  why  perityphlitic  abscesses  should  run 
upward,  while  the  ordinary  psoas  abscesses  of  spinal  caries  run 
doivnivard.  Maydl  answers  that  ths  patients  with  spinal  caries 
are  allowed  to  be  up  and  about,  so  that  their  abscesses  gravitate 
downward  ;  the  patients  with  perityphlitic  abscesses  are  kept  in 
bed  ;  it  is  easy  for  their  abscesses  to  run  upward  behind  the 
ascending  colon  and  the  right  kidney,  and  thus  to  reach  the  sub- 
phrenic region. 


SUBPHRENIC    ABSCESS.  427 

upward  of  the  diaphragm.  For  the  next  nine  days, 
nothing  was  done  ;  no  change  for  the  worse ;  less  pain. 
Oct.  9th,  increased  difficulty  of  breathing,  and  oppres- 
sion. That  evening  he  suddenly  collapsed  ;  and  now, 
for  the  first  time,  signs  were  found  of  fluid  in  the  lower 
part  of  the  right  pleura,  and  auscultation  gave  high- 
pitched  metallic  tinkling  sounds  and  well  marked 
Hippocratic  splash.  Next  day,  the  fluid  in  the  pleura 
was  increased,  and  the  heart  was  displaced  toward  the 
left.  Two  days  later  (Oct.  12th)  resection  was  made  of 
the  seventh  rib,  outside  the  nipple,  and  gas  and  foetid  pus 
escaped.  The  diaphragm  was  felt  to  be  pushed  upward, 
and  very  tense,  moving  only  a  little  in  respiration.  It 
was  explored  with  a  needle,  and  similar  pus  was  drawn 
off.  It  was  incised,  the  opening  dilated,  and  nearly 
a  quart  of  foetid  pus  let  out.  Two  thick  tubes  ;  irrigation. 
He  did  well  at  first  ;  but  the  lung  failed  to  expand, 
and  he  died  exhausted  at  the  end  of  the  month.  No 
post  mortem  examination  was  allou  ed. 

The  prognosis  of  subphrenic  abscess,  as  a  whole,  is 
very  clearly  brought  out  by  Maydl's  work.  Left  to  itself, 
it  is  almost  necessarily  fatal.  Out  of  104  cases  where 
no  operation  was  performed,  only  6  recovered,  by  the 
breaking  of  the  pus  into  the  lung  or  into  the  bowel.'  Of 
the  98  that  died,   77  had  no  surgical   treatment  of  any 


'Dr.  Myrtle  ("Clin.  Soc.  Trans.,"  1890,  vol.  xxiii.,  p.  154) 
records  a  case  where  an  abscess,  after  nephrectomy,  eft  without 
operation,  finally  burst  into  the  lung,  and  the  patient  recovered; 
but  ior  nearly  three  months  she  had  gone  through  very  severe 
suffering. 

Mr.  Wheelhouse  ("Brit.  Med.  Journ,"  ]S8i,  vol.  ii.)  has  re- 
corded two  cases  of  subphrenic  abscess  which  finally  burst  into 
the  bowel,  and  the  patients  recovered  Hofmokl  has  recorded  a 
case  where  the  disease  burst  into  the  lung  ;  the  patient  died.  In 
two  of  these  three  cases,  the  pleura  had  already  been  incised,  and 
pus  let  out. 


42S  SURGERY    OF    THE    CHEST. 

kind,  5  were  punctured  but  nothing,  was  found,  and  i6 
were  punctured  and  the  abscess  was  found,  but  the 
surgeon  did  not  go  on  to  incise  it.  Out  of  these  98 
fatal  cases,  the  abscess  burst  before  death  into  the  lungs 
or  the  bowel  in  19;  but  79  patients  died  unrelieved 
either  by  Nature  or  by  art. 

Out  of  74  cases  treated  by  incision,  with  or  without 
resection,  35  died  and  39  were  saved.  But  these  35 
deaths  want  some  explanation.  In  one  case,  and  in  one 
only,  was  the  operation  itself  the  cause  of  death.  In 
five,  the  surgeon  opened  an  abscess  communicating,  with 
the  subphrenic  abscess,  but  left  the  subphrenic  abscess 
undrained.  In  seven,  he  opened  the  subphrenic  abscess, 
but  left  an  empyema  undrained.  In  nine,  the  operation 
failed  because  there  was  suppuration  in  some  other  more 
or  less  remote  region  of  the  body.  In  four,  there  was 
purulent  peritonitis.  And  in  all  the  rest  there  were 
special  conditions  opposing  themselves  to  the  success  of 
the  operation — pneumonia,  tuberculous  disease  of  the 
kidneys,  pyaemia.  One  patient  died  suddenly  of  syncope 
during  irrigation  ;  in  another,  pleural  adhesions  were 
present  at  the  time  of  operation,  but  broke  down  after  it, 
and  the  patient  died  of  septic  pleurisy  ;  in  another,  the 
subphrenic  abscess  was  opened,  but  incision  of  a  large 
empyema  was  put  off  for  a  day  or  two,  as  the  patient  was 
very  feeble  ;■  and  the  delay  proved  fatal. 

To  attempt  to  cure  subphrenic  abscess  by  aspiration 
is  almost  or  quite  hopeless.  Eight  patients  thus  treated 
all  died  :  one  of  them  two  hours  after  aspiration,  and 
one  a  few  minutes  after  it.  There  seems  to  be  a  special 
risk  of  syncope  in  aspirating  a  subphrenic  abscess  ;  and 
in  addition  to  this,  there  are  all  the  same  difficulties  and 
drawbacks  that  attend  aspiration  of  an  empyema.  There 
is,  so  far  as  I  know,  not  a  single  record  of  recovery  from 


SUBPHRENIC    ABSCESS.  429 

subphrenic  abscess  after  aspiration. 1  Tlie  whole  treat- 
ment of  subphrenic  abscess  has  gone  side  by  side  with  the 
treatment  of  empyema  :  the  same  practice  of  puncture 
and  nspiration,  the  same  fear  of  incision,  the  same  attempt 
to  use  syphon-drainage,  and  the  same  period  of  inaction 
( 1 850-1870)  before  the  New  x'\ge.  Since,  therefore,  in- 
cision is  the  only  proper  treatment  of  subphrenic  abscess, 
we  have  to  ask  what  are  the  chances  that  we  shall  have  to 
open  the  pleura,  and  by  what  method  we  shall  operate. 

Taking  Maydl's  74  cases  treated  by  incision,  with  or 
without  resection,  we  find  that  in  40  of  them  the  operation 
was  done  through  the  chest-wall.  In  34,  the  abscess  was 
reached  by  incision  elsewhere,  e.^:,  through  the  epigas- 
trium, the  hypochondrium,  the  iliac  region  or  the  lorn. 
With  the  fortunes  of  these  34  cases  we  are  not  here  con- 
cerned, as  they  do  not  belong  to  the  surgery  of  the  chest. 
We  must,  however,  note  the  great  difficulty  in  subphrenic 
abscess,  from  perforated  gastric  ulcer,  that  comes  from 
the  burrowing  backward  and  downward  of  the  pus  toward 
the  spleen  ;  the  danger  of  pericarditis  ;  and  the  simula- 
tion of  the  friction-sound  of  pericarditis  caused  by  the 
deposit  of  lymph  on  the  outer  surface  of  the  pericardium, 
as  happened  in  two  of  the  ten  cases  collected  by  Dr. 
Penrose  and  Dr.  Lee  Dickinson.  We  have  also  to 
remember  that  in  no  less  than  9  out  of  these  34  cases, 
the  surgeon  reached  and  drained  the  subphrenic  abscess 
without  going  through  the  chest-wall,  but  left  untouched 

'  '  Beside  other  dangers  of  aspiration,  the  contents  of  a  sub- 
phrenic abscess  are  by  no  means  always  of  a  kind  to  come 
tlirough  an  aspirating-needle.  Thick  like  pea-soup,  or  frothy 
like  yeast,  or  mixed  with  gangrenous  shreds  of  tissue,  hydatid 
membranes,  fragments  of  undigested  food,  or  bits  of  fasces,  the  pus 
is  often  utterly  unable  to  do  anything  of  the  kind.  There  may  be 
a  foreign  body  in  the  cavity ;  or  it  may  communicate  with  the 
alimentary  canal,  the  gall-bladder,  the  bile  ducts,  or  a  cavity 
in  the  lung.'     Maydl,  loc.  cit.  p.  341. 


430  SURGERY    OF    THE    CHEST. 

an  empyema  ;  and  in  i  case,  he  drained  the  subphrenic 
abscess,  and  would  have  incised  the  empyema  also,  but 
the  patient  was  so  feeble  that  he  put  it  off  for  a  day  or 
two.     All  these  lo  patients  died. 

In  the  40  cases  where  the  operation  was  done  through 
the  chest-wall,  in  18  of  them  the  pleura  was  found  shut 
off  by  adhesions;  in  10  there  were  no  adhesions,  and  no 
effusion  ;  in  5  there  was  a  serous  effusion  ;  in  the  remain 
ing  7  there  was  a  purulent  effusion. 

In  some  of  the  cases,  the  incision  through  the  chest- 
wall  was  the  only  one  made,  and  the  diaphragm  was 
incised  through  it,  or  had  already  given  way.  In  others, 
aspiration  or  incision  had  already  been  practised  in  some 
other  region  of  the  body. 

A  good  case  of  direct  incision  of  the  chest-wall  was 
reported  by  Dr.  Hector  Mackenzie  and  Mr.  Abbott 
at  the  Clinical  Society  last  year.  The  patient  was  a 
boy  10  years  old.  The  abscess,  probably  due  to  ruptured 
gastric  or  duodenal  ulcer,  had  already  broken  into  the 
pleura ;  there  was  a  rounded,  red,  acutely  tender  swelling 
in  the  epigastrium,  which  became  more  prominent  and 
fluctuating  when  he  sat  up  or  coughed  ;  and  there  were 
signs  of  pyo-pneumothorax  of  the  right  side.  '  From 
the  physical  signs,  it  was  evident  that  the  communi- 
cation between  the  subphrenic  abscess  and  the  empyema 
was  a  very  free  one,  and  it  was  therefore  decided 
to  drain  both  through  an  opening  in  the  pleura.' 
Resection  of  sixth  rib  just  behind  axillary  line  ;  a  pint 
and  a  half  of  thin  foetid  pus  was  let  out ;  the  lung  at  once 
expanded  well.  The  upper  surface  of  the  liver  was  felt 
through  an  opening  in  the  diaphragm  extending  from 
about  the  tip  of  the  ninth  costal  cartilage  nearly  to  the 
middle  line.  The  exact  limits  of  the  subphrenic, cavity 
were  not  made  out.     The  cavity  was  well  washed  out, 


SUBPHRENIC    ABSCESS.  431 

and  a  double  tube  inserted  into  the  pleura  :  daily  irriga- 
tion ;  wound  healed  in  about  five  weeks ;  complete 
recovery,  with  perfect  expansion  of  lung.i 

As  instances  of  incision  of  the  chest-wall,  subsequent 
to  aspiration  or  incision  of  the  abscess  outside  the  chest, 
we  may  take  the  following  cases  : — A  boy,  15  years  old, 
was  attacked  with  acute  peritonitis,  ending  in  an  abscess 
in  the  lower  part  of  the  abdomen  :  this  was  aspirated, 
and  thin  foetid  pus  was  drawn  off.  About  three  weeks 
later,  there  was  swelling  just  above  the  liver,  giving  a 
tympanitic  note  on  percussion.  The  diaphragm  was 
pushed  upward  ;  there  was  well-marked  friction-sound  at 
the  lower  border  of  the  lung,  and  Hippocratic  splash. 
Some  abdominal  distension  ;  severe  cough  ;  marked  loss 
of  strength.  Resection  was  made  of  the  ninth  rib  ; 
nearly  a  pint  of  foetid  pus  was  let  out ;  the  lung  gradually 
expanded.  No  fluctuation  was  felt  beneath  the  dia- 
phragm. The  boy  died  ten  days  later,  with  signs  of 
peritonitis.  The  post  mortem  examination  showed  diffuse 
peritonitis,  with  adhesions  and  pockets  of  pus  ;  liver 
adherent  to  diaphragm,  except  at  one  place,  where  there 
was  a  circumscribed  abscess.  The  communication 
between  this  and  the  pleura  could  not  be  made  out.  In 
another  case,  a  perityphlitic  abscess  was  opened  (Septem- 
ber 25th)  by  an  incision  in  the  loin,  with  resection  of  the 
twelfth  rib.  On  October  1 3th,  this  incision  was  enlarged, 
and  a  faecal  concretion  was  found  in  the  abscess-cavity. 
On  October  25th,  the  patient  was  found  to  have  empyema 
of  the  right  side ;  the  usual  operation  was  done  for  its 
relief,  and  he  got  well.  In  another,  a  subphrenic  abscess, 
due  to  a  small  hydatid  cyst,  and  containing  gas  as  well  as 

^  "The  surgical  treatment  in  this  case  was  merely  that  of  an 
ordinary  empyema,  and  the  sub-diaphragmatic  abscess  drained 
excellently  by  this  route,  better  than  it  could  possibly  have  done 
through  an  incision  immediately  over  it." 


4j2  SURGERY    OF    THE    CHEST. 

pus,  was  treated  by  exploratory  puncture ;  and  this  was 
followed  by  high  fever.  A  piece  of  the  seventh  rib  vvas 
therefore  resected  in  the  nipple  line,  and  the  abscess  was 
freely  incised  :  the  pleura  was  not  opened.  A  counter- 
opening  was  made  below  the  ribs.  The  patient  did  well 
for  a  month,  then  got  influenza,  and  was  found  to  have 
empyema  of  the  right  side.  This  was  treated  by  the  usual 
operation,  but  he  died  of  pneumonia  and  exhaustion  12 
days  later. 

Of  subphrenic  abscess  secondary  to  amte  iiiflammation 
wiihm  the  chest,  Maydl  has  collected  9  instances.  The 
primary  diseases  were  as  follows  : — in  3  cases,  gangrene 
of  the  lung ;  in  2,  empyema ;  in  2,  pleuro-pneumonia  ; 
in  I,  gangrenous  empyema;  in  1,  abscess  of  the  lung. 
One  case,  in  which  the  diagnosis  was  not  absolutely  cer- 
tain, recovered  without  operation  ;  one  recovered  after 
operation  ;  the  rest  died,  either  without  any  operation, 
or  after  simple  puncture  without  incision. 

Eight  of  the  cases  I  put  in  the  note  here.^    They  show 

'  I,  A  man,  31  years  old,  was  admitted  to  Hospital  on  June 
20th,  1869.  There  was  dulness  of  the  right  side  up  to  the  nipple- 
hne,  and  the  liver  came  well  below  the  ribs.  The  diagnosis  was 
'  hyperaemia  of  the  liver.'  August  ist — 3rd,  pains  in  epigastrium 
and  right  side,  feeling  of  suffocation,  impeded  movement  of  right 
side,  nothing  found  amiss  in  heart  or  lungs.  The  diagnosis  was 
changed  to  '  diapliragmatic  pleurisy.'  August  7th,  dulness  and 
loss  of  breath-sounds  up  to  angle  of  scapula,  redness  and  oedema 
of  skin  of  right  hypochondrium.  The  diagnosis  was  again  changed 
to  '  pyo-pneumothorax,  probably  due  to  abscess  of  the  liver.' 
August  gth,  general  condition  worse ;  swelling,  tenderness,  and 
emphysema  of  skin  above  nipple;  puncture  in  the  third  space  let 
out  foetid  gas.  Two  days  later,  turbid  foetid  fluid  began  to  ooze 
through  the  punctures.  Three  days  later  he  died.  Tost  mortem, 
gangrenous  empyema,  gangrenous  softening  and  perforation  of 
the  diaphragm,  leading  into  a  foetid  subphrenic  abscess. 

2.  A  man,  aged  21,  after  pneumonia,  had  empyema  of  the 
right  side.  This  was  treated  by  incision  with  resection.  A  few 
days  later,  during  irrigation  of  the  cavity,  he  suddenly  died. 
Post  mortem,  serous  pericarditis,  three  and  a  half  pints  of  pus  in 


SUBPHRENIC    ABSCESS.  433 

clearly  how  hard   may  be  the  diagnosis  of  acute  inflam- 

the  right  pleura,  and  a  small  perforation  of  the  diaphragm,  lead- 
ing into  a  cavity  to  the  left  of  the  suspensory  Ugament. 

3.  A  man  suffering  urgent  dyspnoea  was  admitted  to  Hospital, 
and  died  soon  after  puncture  of  the  chest.  Post  mortem,  more 
than  five  pints  of  pus  in  the  right  pleura,  perforation  of  dia- 
phragm, subphrenic  abscess,  pericardial  adhesions. 

4.  A  man,  aged  48,  was  admitted  to  Hospital  on  March  23rd, 
suffering  colic  and  pains  in  the  stomach.  His  illness  began  nine 
days  ago,  with  intense  abdominal  pain;  he  vomited  twice  the  first 
day,  but  not  since.  Next  day  there  was  tenderness  of  the  abdomen, 
with  pain  in  the  left  hypochondrium,  shooting  up  to  the  left  shoul- 
der ;  liver  two  fingers  breadth  below  ribs,  prolonged  expiration 
below  both  clavicles,  with  mucous  rales.  The  first  diagnosis, 
'  tubercular  phthisis  in  its  earliest  stage '  was  now  changed  to 
'abscess  within  the  chest.'  A  week  later,  he  coughed  up  four  or 
five  ounces  of  pus  and  blood  together,  and  this  was  followed  by 
intense  abdominal  pain  and  oppression,  slight  dulness  over  both 
bases.  The  diagnosis  was  now  again  changed  to  '  abscess  either 
in  the  liver  or  in  the  pleura.'  On  April  12th  he  died.  Postmortem, 
gangrene  of  the  whole  under  aspect  of  the  lower  lobe  of  the  left 
lung,  perforation  of  the  diaphragm,  subphrenic  abscess. 

5.  A  man,  aged  19,  was  in  Hospital  supposed  to  be  suffering 
from  tubercular  disease  of  both  apices,  serous  pericarditis,  and 
right  pleural  effusion.  Post  mortem,  sero-purulent  pericardial 
effusion,  with  fibrinous  deposit.  At  the  base  of  the  right  lung, 
diffuse  purulent  infiltration,  and  in  one  place  a  circumscribed 
abscess.  Multiple  perforations  of  the  diaphragm,  and  subphrenic 
abscess. 

6.  A  woman,  aged  40,  insane,  was  supposed  to  be  suffering 
from  slow  tubercular  disease  of  the  right  lung  Post  mortem, 
gangrene  of  the  lower  lobe  of  the  right  lung,  and  of  the  diaphragm 
beneath  it,  and  subphrenic  abscess.  Double  sero-fibrinous  pleural 
effusion,  fibrinous  pericarditis. 

7.  A  woman,  aged  58,  post  mortem  record  only.  Gangrenous 
exudation  over  lower  part  of  right  pleura  and  lung.  On  the  under 
aspect  of  the  lower  lobe,  an  opening  in  the  lung,  leading  into  a 
gangrenous  cavity  in  it.  The  diaphragm  was  perforated  in  many 
places,  and  there  was  a  gangrenous  abscess  in  the  liver. 

8.  A  man,  aged  27,  was  admitted  to  Hospital  with  double 
pleuro-pneumonia,  and  diaphragmatic  pleurisy.  Ten  days  later, 
there  was  increased  pain  in  the  right  hypochondrium,  and  a 
rounded  tense  fluctuating  swelling  could  be  made  out  here.  The 
liver  dulness  extended  upward  to  the  nipple,  and  downward  four 
fingers'  breadth  below  the  ribs  ;  the  veins  over  the  swelling  were 
enlarged.  A  fortnight  later,  the  swelling  could  no  longer  be  felt 
to  fluctuate,  and  a  fortnight  later  it  was  gone.  He  made  a  com- 
plete recovery. 

28 


434  SURGERY    OF    THE    CHEST. 

mation  inside  the  chest  ending  in  perforation  of  the 
diaphragm,  and  how  useless  it  is  to  attempt  to  cure  these 
cases  by  puncture.  The  ninth  and  most  important  case 
was  pubhshed  by  Meltzer  in  1893  : — 

A  child,  between  2  and  3  years  old,  after  two  attacks  of 
acute  pneumonia,  was  again  taken  ill  with  high  fever,  sweats, 
acute  swelling  of  the  spleen  ;  the  liver  was  felt  below  the 
ribs,  and  there  was  pain  in  the  right  hypochondrium,  with 
dulness  over  the  right  base  behind,  and  loss  of  breath-sounds 
and  of  vocal  vibration.  On  the  6th  day,  42  days  after  the 
first  attack  of  pneumonia,  an  exploratory  puncture  was  made, 
and  pus  was  drawn  off.  The  diagnosis  of  empyema  thus 
seemed  absolutely  certain.  Next  day,  an  inch-and-a-half  of 
the  eight  rib  were  resected,  about  the  posterior  axillary 
line ;  a  second  puncture  was  now  made,  and  pus  was  again 
found.  The  pleura  was  incised,  but  only  about  half  a  tea- 
spoonful  of  pus  came  out.  '  My  wound  was  large  enough  for 
me  to  see  how  the  diaphragm,  fixed  and  tense,  was  pushed 
upward  into  the  chest.  The  lung  was  not  wholly  collapsed;  I 
felt  its  lower  edge,  which  was  somewhat  thickened.  There 
were  neither  adhesions,  nor  a  circumscribed  empyema,  but  I 
could  feel  distinct  fluctuation  all  over  the  diaphragm;  in  a 
word,  I  had  to  do  with  a  subphrenic  abscess.  On  close 
examination,  I  observed  a  pin-point  opening  in  the  diaphragm, 
whence  had  come  the  few  drops  of  pus  in  the  pleura.  I  dilated 
it,  fitted  a  big  tube  into  it,  and  by  gentle  pressure  on  the  dia- 
phragm got  out  the  pus  without  soiling  the  pleura.  Then  I 
explored  the  cavity  with  my  finger ;  several  empty  pockets 
opened  into  it.  The  upper  surface  of  the  liver  was  perfectly 
smooth.'  The  temperature  ran  high  for  several  days,  but 
was  brought  down  with  quinine.  The  tube  was  removed  at 
the  end  of  three  weeks.     Complete  recovery. 

It  is  evident  that  the  operation  for  subphrenic  abscess 
has  no  fixed  method  for  every  case.  We  must  be  guided 
by  the  history  of  the  patient,  the  situation  of  the  primary 
disease,  the  physical  signs,  and  the  evidence  of  ex- 
ploratory puncture.  One  thing  is  certain,  that  the 
patient  must  not  be  left  without  operation,  and  that  any 
treatment  short  of  incision  and  thorough  drainage  is 
useless. 


SUBPHRENIC    ABSCESS.  435 

Operation  through  the  Pleura  for  Hydatid  Cyst 
OF  THE  Liver. 

It  is  plain  that  a  hydatid  cyst  of  the  upper  surface  of 
the  liver,  kidney,  or  spleen,  growing  upward  beneath 
the  ribs,  may  be  accessible  to  free  incision  only  by  an 
operation  through  the  chest-wall :  it  is  indeed  a  huge 
subphrenic  cyst  or  abscess.  To  Maydl's  collection  of 
17  cases  of  this  kind,  several  others  may  now  be  added, 
published  by  Mr.  Tyson,  Dr.  Rudall,  and  others ;  and 
two  which  I  published  last  year.'  The  difficulties  of 
diagnosis,  in  these  cases  where  the  disease  does  not  come 
forward  beneath  the  ribs,  are  very  great :  the  diagnosis 
usually  made  is  '  hepatitis '  or  'hepatic  colic,'  or  'pleurisy 
with  effusion.'  The  very  slow  growth  of  the  cyst,  the 
irregularity  and  intermittence  of  the  symptoms  due  to  it, 
the  absence  of  any  visible  or  tangible  swelling  below 
the  ribs — all  these  make  early  diagnosis  almost  im- 
possible, especially  as  one's  thoughts  are  not  at  all 
likely  to  be  set  in  the  direction  of  hydatid  disease. 
Thus  these  cases  of  what  we  may  call  '  hidden  hydatid ' 
are  full  of  clinical  interest ;  and  the  list  of  wrong  dia- 
gnoses is  of  considerable  length.  It  is  indeed  more 
important  to  study  their  history  before  operation  than  to 
note  the  technique  of  the  operation  itself;  for  the  rules 
for  the  thoracic  operation  for  hydatid  ot  the  liver  are 
the  same  as  those  for  subphrenic  abscess  or  for  abscess 
of  the  liver,  when  these  have  to  be  attacked  through  the 
chest-wall :  careful  exploratory  puncture,  occlusion  of 
the  general  cavity  of  the  pleura,  free  incision  of  the 
cyst,  and  free  drainage.  A  very  large  drain  is  needed  : 
the  rubber  tube  sold  for  gas-piping  is  more  to  the  pur- 
pose than  ordinary  surgical  drainage-tube. 

1  See  "Clin.  Soc.  Trans.,"  1888  and  1894;  "British  Med. 
Journal,"  July  6,  and  Nov.  2,  1895. 


436  SURGERY    OF    THE    CHEST. 

Of  Maydl's  1 7  cases,  9  were  female  ;  6,  male ;  in  2, 
sex  not  stated.  As  to  age,  12  were  between  20  and 
40  years  old,  and  the  rest  were  over  40.  We  must  keep 
in  mind  the  possibility  that  a  subphrenic  hydatid  cyst 
may  have  its  starting-point  not  in  the  liver,  but  in  the 
loose  cellular  tissue  between  it  and  the  diaphragm ; 
or  in  the  kidney,  or  in  the  spleen. 

The  continued  flow  of  bile  from  the  operation-wound 
may  severely  weaken  the  patient ;  but  I  know  of  no  case 
where  it  proved  fatal.  Maydl  says  of  it :  '  This  flow  of 
bile  may  come  on  some  time  after  the  operation,  when 
the  cyst-wall  begins  to  come  away.  Often  it  lasts  for 
weeks,  and  only  subsides  when  it  has  brought  the  patient 
to  the  brink  of  the  grave.  Out  of  my  17  cases,  5  suf- 
fered from  it ;  but  in  none  did  it  prevent  final  complete 
recovery,  though  some  had  come  very  low  by  the  time 
it  ceased  :  nor  do  we  clearly  know  what  made  it  cease. 
In  one  case,  to  stop  it,  two  ribs  were  resected,  and  this 
procedure  appeared  to  be  successful.  The  resection 
either  helped  the  cavity  to  close,  or  obliterated  the  open 
mouth  of  the  sinus  through  which  the  bile  was  flowing.' 

My  own  two  cases  were  as  follows  : — 

I.  A  man,  28  years  old  :  his  troubles  began  seven  years 
ago,  when  he  was  taken  ill,  somewhat  suddenly,  with  sharp 
pain  and  tenderness  in  the  region  of  the  gall-bladder, 
vomiting,  and  jaundice,  and  was  laid  up  for  some  weeks. 
The  diagnosis  on  this  occasion  was  '  biliary  gravel,'  and  it 
was  thought  that  the  gall-bladder  could  be  felt  enlarged. 
From  this  time  onward  he  was  subject  to  similar  attacks, 
which  occurred  suddenly  and  at  irregular  intervals  about 
twice  a  year.  Between  them,  he  was  in  his  usual  good 
health.  In  some  of  them,  he  was  not  jaundiced ;  but,  with 
this  exception,  they  were  all  very  much  alike  :  sudden  in 
their  onset,  slow  to  pass  away,  marked  by  severe  pain  and 
tenderness  about  the  region  of  the  gall-bladder  ;  and,  in  the 
later  attacks,  the  pain  used  to  shoot  round  to  the  back,  and 
up  to  the  right  shoulder.     In  the  autumn  of  1894  he  had  an 


SUBPHRENIC    ABSCESS.  437 

attack  of  unusual  severity,  which  lasted  many  weeks  ;  his 
pain  was  aggravated  by  obstinate  constipation,  with  accumu- 
lation of  wind  in  the  bowels.  On  Dec.  13th,  1894,  he  had, 
for  the  first  time,  a  rigor  :  others  occurred  on  the  21st  and 
22nd,  and  on  the  24th  there  were  signs,  not  well  marked,  ot 
a  slight  pleural  effusion  in  front,  immediately  above  the  liver: 
about  this  time  also  he  began  to  be  troubled  with  sweats, 
which  were  at  times  very  profuse.  But  the  signs  of  effusion 
passed  off,  and  so  did  the  sweats  ;  and  during  the  greater 
part  of  January,  and  the  first  half  of  February,  his  tempera- 
ture was  about  normal,  and  he  seemed  once  more  to  be 
convalescent.  But  on  Feb.  14th  he  again  had  a  rigor,  with 
temp.  102°,  and  in  March  his  temperature  was  hectic,  loi" 
or  102°  every  night  :  he  was  frequently  in  pain,  and  was 
plainly  losing  ground.  His  condition  just  before  operation 
(March  28th)  was  as  follows  :  Though  he  did  not  appear  in 
immediate  danger  of  his  life,  he  was  very  weak  and  feverish, 
restless,  and  depressed,  suffering  from  severe  lancinating 
pains  not  only  in  the  region  of  the  liver,  the  right  side,  and 
the  right  shoulder,  but  also  up  the  spine  to  the  back  of  the 
head,  and  down  the  backs  of  both  thighs  to  the  calves. 
There  was  no  enlargement  of  the  front  of  the  liver,  noi 
could  its  edge  be  felt  below  the  ribs,  nor  was  there  any 
increase  of  the  liver  dulness  in  front.  Behind,  in  the  line  of 
the  angle  of  the  scapula,  there  was  slit^ht  dulness  over  the 
lower  ribs,  from  the  seventh  to  the  tenth,  and  the  intercostal 
spaces  here  felt  somewhat  firmer  than  natural.  And  it  is 
worth  noting  that  when  this  area  was  percussed,  the  patient 
himself  felt  a  distinct  thrill  or  wave  in  the  region  of  the 
liver.  The  significance  of  these  signs,  and  of  the  whole 
history  of  the  case,  was  pointed  out  by  Dr.  Douglas  Powell, 
who  kindly  saw  the  patient  with  me,  and  made  the  dia- 
gnosis of  suppurating  hydatid.  Operation :  Exploring  syringe 
put  in  at  ninth  right  space,  just  below  angle  of  scapula, 
and  thrust  straight  forward  for  3I  or  4  inches,  and  pus  found. 
Needle  left  in  sitil  as  a  guide  ;  resection  of  3  inches  of  ninth 
rib ;  the  pleura  was  laid  open  freely,  and  air  was  drawn  into 
it  with  each  inspiration.  No  pleural  adhesions,  no  fluid  in 
pleura,  lung  not  seen.  The  diaphragm  was  very  tense,  and 
was  pushed  up  so  high  that  it  was  almost  vertical  ;  it  moved 
hardly  at  all  in  respiration.  There  was  a  clear  space,  from 
h  to  I  inch,  between  it  and  the  chest-wall.  I  fastened  the 
diaphragm  to  the  pleura,  putting  in  two  stitches  with  a  strong 
curved  needle  on  a  long  handle  ;  the  needle  was  passed  first 
through  the  diaphragm,  taking  firm  hold  on  it,  then  through 


438  SURGERY    OF    THE    CHEST. 

the  pleura  —it  was  impossible  to  pass  it  the  reverse  way,  as 
the  diaphragm  kept  moving  just  out  of  reach.  Then  1 
incised  the  diaphragm,  punctured  the  cyst,  dilated  the 
opening,  laid  the  cyst  freely  open,  and  fastened  it  in  the 
wound.  About  a  quart  of  purulent  fluid  and  cysts  were  let 
out.  Irrigation;  drainage  for  four  weeks ;  lung  quickly  ex- 
panded ;  recovery.  A  very  little  bile  flowed  through  the 
wound,  but  not  after  the  first  week  or  ten  days. 

2.  A  man,  aged  50,  syphilitic,  given  to  drink  :  arteries 
rigid,  well  marked  arcus  senilis.  Two  and  a-half  years  ago, 
he  suffered  pain  in  the  region  of  the  liver,  shooting  up  to  the 
right  shoulder,  continuous,  not  paroxysmal,  worse  on  deep 
inspiration  ;  had  also  abdominal  pains,  and  was  jaundiced. 
Was  in  Hospital  five  weeks  ;  his  board  was  headed, 
'  Hepatitis,'  and  the  notes  say,  '  Pain  in  the  right  side, 
tenderness  over  the  ninth  rib,  and  a  doubtful  feeling  of  ful- 
ness on  the  right  side.'  His  temperature  was  raised  to  loi*' 
or  102''  every  night  for  three  weeks.  Then  the  pains  and 
fever  ceased,  he  left  the  Hospital,  and  nothing  was  heard  of 
him  for  two  and  a  half  years.  Then  he  came  back,  having 
had  a  second  attack  of  jaundice,  followed  by  return  of  his 
old  pains.  His  condition  just  before  operation  was  almost 
hopeless.  Apart  from  his  being  in  every  way  a  bad  subject 
for  an  operation,  he  had  steadily  refused  it  up  to  the  last 
moment,  and  had  taken  a  great  change  for  the  worse  in  the 
last  twenty-four  hours.  Peritonitis  had  already  set  in  ;  his 
temperature,  after  standing  at  100°  to  103°  for  many  days, 
had  suddenly  dropped;  tongue  dry,  pulse  quick  and  feeble, 
breathing  shallow  and  painful,  face  thin  and  drawn,  jaundice, 
frequent  vomiting,  diarrhoea,  and  utter  exhaustion.  The 
liver  was  3^  inches  below  the  ribs,  and  its  vertical  dulness, 
in  the  nipple  line,  was  6^  inches;  but  the  surface  thus 
exposed  did  not  feel  tense,  nor  did  it  raise  the  abdominal 
wall  over  it  to  any  marked  extent.  In  the  axillary  line, 
dulness  began  at  the  lower  border  of  the  seventh  rib ; 
the  breath-sounds  at  the  base  of  the  lung  were  normal. 
Operation  :  As  tlie  liver  reached  so  far  below  the  ribs  in 
front,  I  hoped  to  reach  the  cyst  here,  so  opened  the  abdomen 
through  the  right  rectus  muscle.  More  than  half  a  pint  of 
turbid  fluid  ran  out,  with  flakes  of  lymph.  The  liver 
appeared  smooth,  soft,  and  of  natural  colour  and  outline  : 
plainly  it  was  depressed  by  soine  growth  in  the  upper  pos- 
terior part  of  it.  I  explored  it  in  two  places  to  a  depth  of  2 
or  i\  inches,  but  only  blood  came.  I  now  stopped  the 
oozing  from  the  needle-holes  by  putting  a  fine  stitch  into 


SUBPHRENIC    ABSCESS.  439 

them,  closed  the  abdominal  wound,  made  a  small  incision 
over  the  dull  area  behind,  and  thrust  a  syringe  well  forward 
through  the  eighth  space  in  the  posterior  axillary  line,  and 
found  pus.  I  used  the  needle  as  a  guide,  resected  the  ninth 
rib,  and  came  straight  down  on  the  naked  fibres  of  the 
diaphragm  at  their  insertion  into  the  tenth  rib,  and  did  not 
open  the  pleura.  Cyst  opened  and  drained.  The  peritonitis 
made  the  operation  hopeless  from  the  first,  and  the  patient 
died  the  next  day.  Post  morlein,  a  large  thick-walled  hydatid 
cyst,  8  or  9  inches  in  diameter,  growing  from  the  upper  pos-^ 
terior  aspect  of  the  liver.  Peritonitis  ;  and  about  a  pint  of 
sero-purulent  fluid,  with  flakes  of  lymph,  in  the  right  pleura. 
The  cyst  lay  so  far  back  that  it  would  have  been  impossible 
to  reach  it  from  the  front. 

These  two  cases  are  good  instances  of  the  difificulty 
of  diagnosis  of  a  '  hidden  hydatid  '  of  the  liver.  The 
first  had  been  diagnosed,  7  years  ago,  as  disease  of 
the  gall-bladder  ;  the  second,  2\  years  ago,  as  'hepatitis.' 
In  both  of  them,  the  disease  advanced  not  regularly 
but  by  fits  and  starts  :  a  short  sharp  attack  of  illness  was 
followed  by  a  long  period  of  apparent  health.  The  first 
patient  had  many  attacks  of  this  character  ;  the  second 
had  an  interval  of  2  J-  years  between  two  attacks.  Again, 
in  the  first  case,  the  liver  was  not  below  the  ribs  at  all ; 
in  the  second,  it  was  below  the  ribs,  but  not  tense  or 
prominent.  Under  such  conditions,  diagnosis  is  well-nigh 
impossible.  What  finally  led  toward  a  right  view  of  the 
two  cases  were  the  occurrence  of  fever,  rigors,  and 
sweats,  the  gradual  extension  of  the  diffusion  of  the  pain, 
the  gradual  increase  of  pressure  upward  and  backward, 
and  at  last  the  slow  deterioration  of  both  patients  :  in 
spite  of  most  careful  treatment  and  nursing,  they  were 
going  from  bad  to  worse,  losing  flesh  and  strength,  with 
steady  increase  of  fever  and  of  pain. 

Of  Maydl's  17  cases,  14  were  submitted  to  operation; 
9  with  incision  and  resection  ;  5  with  incision  only ;  in 
2  of  these  5,  there  was  an  abscess  pointing  under  the 


440  SURGERY    OF    THE    CHEST. 

skin,  which  was  found  to  lead  by  a  fistulous  track  into 
the  cyst.  Of  these  14,  8  were  cured,  and  6  died  in  spite 
of  operation ;  in  2  of  the  6,  the  cavity  was  well  advanced 
toward  healing ;  and  death  was  due  to  phthisis  in  one 
case,  and  influenza  in  the  other. 

I  have  done  my  best  to  put  clearly  the  work  that  is 
now  being  done,  in  England  and  in  other  countries,  in 
one  field  of  surgery.  The  record  of  the  last  twenty 
years  is  wonderful  indeed,  and  we  have  gone  forward  so 
far  and  so  fast,  that  what  we  want  now  is  rather  to  see 
more  readily  and  more  accurately  the  indications  for 
operation,  than  to  invent  new  methods  of  operating. 
'  The  wheel  has  come  full  circle ' ;  the  discoveries  of 
Lister  have  brought  us  back  to  the  free  incision  practised 
by  Hippocrates.  To  Lister's  work  we  might  apply 
Pope's  fine  saying  : — 

"  Nature  and  Nature's  works  lay  hid  in  night ; 
God  said,  'Let  Newton  be,'  and  all  was  light :  " 

and  as  I  have  put  Paget's  name  on  the  first  page  of 
this  book,  so,  with  the  same  gratitude  for  his  teaching 
and  for  the  example  of  his  life,  I  write  Lister's  name  on 
the  last. 


APPEiNDICES 


443 


APPENDIX   A. 

M.  RECLUS'  ADDRESS  AT  THE  FRENCH   SURGICAL 
CONGRESS,  1895. 

When  it  was  proved  by  experiment  that  one  could  remove 
the  whole,  or  part  of  the  lung  of  a  rabbit,  without  seriously 
injuring  it,  it  seemed  certain  that  the  surgery  of  the  lung  had 
a  splendid  future  before  it.  We  were  told  that  its  delicate 
texture,  and  its  relation  to  the  life  of  the  blood,  and  its  near- 
ness to  the  heart,  are  no  real  reasons  a<^ainst  operating  on  it, 
and  that  the  surgeon  has  as  much  right  to  interfere  with  the 
lung  as  with  the  limbs  or  face  ;  and  Gliick  went  so  far  as  to 
quote  the  old  saying,  "  Ubi  hasmorrhagia,  ibi  ligatura  ;  ubi 
tumor,  ibi  extirpatio  ;  ubi  pus,  ibi  incisio."  How  far  shall  we 
accept  this  threefold  assertion  ?  Our  answer  must  rest  on  the 
hard  facts  of  experience  ;  and  we  shall  be  able  to  give 
it  now,  for  we  have  been  interrogating  the  surgery  of  the 
lung  for  the  last  twenty  years  after  a  truly  scientific  method, 
in  the  strength  of  the  work  of  the  present  time. 

The  New  Age  began  when  Neisler,  in  1873,  opened  a  cavity 
in  the  lung  of  a  phthisical  patient,  59  years  old  ;  and  from 
that  time  onward  we  have  records  of  many  operations  and  of 
many  methods.  I  had  thought  to  tabulate  them  all  ;  but 
True  gives  most  of  the  cases  up  to  1885  ;  so  I  advise  you  to 
study  his  excellent  book  for  these  earlier  records,  and  I  shall 
tabulate  the  cases  of  the  last  ten  years,  1885-1895,  and 
no  others.  The  conditions  of  the  lung  that  may  at  the 
present  day  call  for  the  help  of  surgery  have  a  very  wide 
range,  but  we  may  divide  them  with  fair  accuracy,  according 
to  Gliick's  aphorism.  There  are  the  haemorrhages,  either 
from  injury  or  disease,  that  may  require  a  ligature  ;  the  new 
growths,  represented  by  tubercular  growths  and  malignant 
disease,  that  may  need  extirpation  ;  finally,  there  are  the 
cavities — fluid  or  putrid  masses  within  the  lung,  phthisical 
cavities,  br  nchiectasis,  localized  gangrene,  abscess,  hydatid 
cyst  :  here  the  treatment  is  a  more  simple  affair —incision, 
not  excision. 


444  SURGERY    OF    THE    CHEST. 

I. 

Seldom  indeed  have  surgeons  interfered  in  hEemorrhage 
from  the  hmg  due  to  injury  :  we  have  no  facts  to  go  upon. 
There  are  the  two  cases  reported  by  Omboni  and  Delorme  ; 
shall  we  be  discouraged  that  they  failed  ?  I  think  not. 
I  believe  that  in  a  case  of  haemorrhage  persisting  in  spite  of 
rest,  immobilization  of  the  chest-wall,  and  occlusion  of  the 
wound,  if  the  loss  of  blood  is  endangering  the  patient's  life, 
is  filling  the  pleura,  and  threatening  to  stop  the  action  of  the 
heart,  or  of  the  lung,  then  a  free  opening  into  the  chest  will 
enable  the  surgeon  to  stop  the  bleeding,  by  tying  the  vessel, 
or  the  piece  of  lung  which  is  wounded,  or  by  packing  the 
wound  with  iodoform  gauze.  If  we  wait,  the  patient  may 
bleed  past  hope  of  help  :  on  the  other  hand,  we  must  not 
forget  that  it  is  a  very  serious  business  to  interfere  in  these 
cases,  to  inflict  the  shock  of  operation  on  a  patient  already 
enfeebled,  and  to  induce  pneumothorax  of  the  whole  side  of 
the  chest,  over  and  above  the  disadvantages  which  are 
already  hindering  the  vital  changes  in  the  blood. 

And  here  we  may  recall  Simpson's  attempt  to  establish  a 
surgical  treatment  of  pulmonary  apoplexy.  In  1890  he 
published  4  cases  of  haemorrhage  into  the  lung-tissue 
with  oedema.  The  symptoms  were  of  such  a  character  that 
there  was  no  hope  of  recovery.  The  haemorrhages  were 
treated  with  aspiration  through  the  fifth  space,  done  under 
circumstances  of  the  greatest  urgency.  The  quantity  of 
blood  withdrawn  was  in  one  case  I2j^  ounces  ;  in  another, 
the  oedema  was  so  great  that  onlj'  serum  came  out.  There 
was  transient  relief,  but  none  of  the  patients  recovered. 

II. 

That  we  have  so  few  facts  to  help  us,  shows  that  the 
ligature  has  not  yet  come  to  be  used  for  haemorrhages  from 
the  lung  ;  and  Gliick's  hopes  of  it  have  still  to  be  realized. 
He  is  no  less  at  fault,  rather  more,  as  to  the  surgical  treat- 
ment of  new  growths  of  the  lung  ;  operation  for  their 
removal  is  the  exception,  not  the  rule  ;  and  since  the  time 
when  one  surgeon  put  an  end  to  his  life,  having  lost  a  patient 
immediately  after  operation  for  removal  of  the  apices  of  the 
lungs,  the  number  of  resections,  in  spite  of  one  or  two  very 
remarkable  cases,  has  remained  so  small  that  one  can  hardly 
take  them  seriously. 

Resection  of  lung-tissue  has  been  practised  for  the  removal 
either  of  tubercular  masses,  or  of  nodules  of  cancer,  usually 


APPENDIX    A.  445 

the  former.  The  four  cases  quoted  by  True  all  ended  fatally 
within  a  fortnight  of  the  operation.  On  the  other  hand  my 
colleague,  M.  Tuffier,  has  recorded  a  brilliantly  successful 
case,  and  Mr.  Lowson  has  done  the  same.  But  these  two 
successes,  which  reflect  so  much  honour  on  the  skill  of  those 
who  won  them,  do  they  change  the  impression  that  we  have 
got  from  the  failures?  No,  they  do  not;  resection  of  the 
lung  for  tubercular  disease  seems  to  me  condemned  past 
appeal.  Either  the  disease  is  diffused  through  one  or  more 
lobes,  and  then  the  attempt  is  too  dangerous,  the  patient  is 
too  weak  and  ill  to  stand  such  mutilation  ;  or  it  is  of  slight 
extent,  limited  to  one  apex,  as  in  Tuffier's  case,  and  then  one 
may  hope  that  medical  treatment  will  get  the  iDetter  of  it  at 
less  risk  to  the  patient.  This  argument  is  so  unanswerable, 
that  Mr.  Lowson's  operation,  in  spite  of  its  splendid  success, 
seenis  to  have  closed  the  list  of  resections  for  tubercular 
disease. 

Cases  of  resection  for  cancer  are  still  more  rare.  Every- 
body quotes  the  case  published  by  Dr.  Anthony  Milton, 
of  Georgia,  who  says  that  he  removed  the  fifth  and  sixth  ribs 
which  were  ca?iotis,  and  two-thirds  of  one  of  the  lobes  of  the 
right  lung  ;  the  patient  lived  four  months  after  the  operation. 
But  was  it  really  cancer?  The  cases  of  Kronlein,  Miiller  and 
Weinlechner  are  more  to  the  point. 

And  I  would  call  your  attention  to  a  case  published  by 
Demons,  in  1886,  of  resection  of  a  hernia  of  the  lung,  which 
issued  through  a  wound  of  the  chest-wall  between  the  ninth 
and  tenth  ribs.  The  swelling  was  half  the  size  of  one's  fist ; 
on  the  first  day  it  was  pink,  polished,  and  soft,  yet  nc 
attempt  was  made  to  reduce  it  ;  next  day,  it  was  congested  ; 
and  after  eight  days,  when  it  was  irreducible,  and  already 
gangrenous,  it  was  removed  with  an  ecraseur,  and  the  wound 
healed.  But  this  operation  might  have  been  avoided,  if  the 
surgeon  had  reduced  the  hernia  early  while  it  was  still  soft 
and  pliable  ;  or,  having  left  it  eight  days,  he  might  have  left 
it  altogether,  for  the  gangrenous  portion  would  have  come 
away,  and  the  stump  would  have  healed  rapidly.  We  need 
hardly  give  the  title  of  resection  to  this  very  modest  pro- 
ceeding. 

Such  to  the  best  of  my  knowledge  is  a  fair  statement 
of  the  case  for  resection  ;  we  need  not  give  this  title  to 
the  removal  of  the  sloughs  in  gangrene,  for  here  no 
healthy  tissue  is  incised.  What  conclusions  are  we  to  draw 
from  these  observations  ?  In  certain  exceptional  cases  of 
extension  of  a  growth  from  the  chest-wall  to  the  lung,  the 


446  SURGERY    OF    THE    CHEST. 

resection  of  the  diseased  parts  of  the  lung  may  be  defended, 
though  in  the  majority  of  these  cases  it  is  best  to  abstain 
from  operation  ;  but  resection  for  primary  cancer  is  con- 
demned past  appeal.  With  Konig,  Peyrot,  and  Forgue,  we 
say  that  it  is  impossible  to  do  such  an  operation  without  first 
setting  at  defiance  the  essential  facts  of  pathology.  Either 
the  disease  is  a  small  isolated  growth,  and  then  there  is  no 
sign  of  its  presence,  or  it  is  large,  diffuse,  and  multiple,  and 
then  to  remove  it  is  sheer  homicide.  In  spite  of  Gliick  there 
is  no  reason  in  resecting  the  human  lung,  or  in  arguing  from 
rabbits  to  men. 

III. 

Our  third  group  of  lesions  that  are  within  the  reach  of 
surgery  includes  the  cavities,  with  walls,  more  or  less  well- 
defined,  and  filled  with  stagnant  debris  of  secretions  of  all 
kinds.  These  morbid  conditions  that  may  need  incision  are 
many  in  number,  and  we  must  take  into  consideration  tuber- 
cular cavities,  bronchiectasis,  gangrene,  abscess,  and  hydatid 
cysts.  Here  there  is  less  risk  in  interfering,  and  Gluck's 
aphorism — "  ubi  pus  ibi  incisio '' — may,  I  believe,  be  admitted 
almost  without  reserve.  And  here  too  we  have  more 
material  to  decide  upon  :  there  is  a  good  collection  of 
memoirs  and  lists  of  cases,  and  the  conclusions  drawn  from 
all  this  wealth  of  careful  work  seem  to  deserve  that  we  should 
loyally  accept  them  ;  and  in  particular  I  would  mention  the 
observations  published  by  Fabricant  ^  in  1894,  which  have 
been  of  great  use  to  me  in  preparing  this  report. 

A. — Tubp:rcul.\r  Cavities. 

I  shall  take  tubercular  cavities  and  dilatation  of  the 
bronchi  together — not  because  they  have  often  been  mis- 
taken one  for  another,  for  we  may  now  avoid  this  by  a 
bacteriological  examination,  but  because  the  indications  for 
operation  are  almost  exactly  the  same  in  the  two  diseases. 
In  spite  of  our  first  enthusiasm,  we  must  interfere  only  in  ex- 
ceptiona  cases  ;  and  even  if  the  cavity  or  the  troubles  that 
come  of  it  can  be  improved  by  incision,  the  original  cause  of 
them,  the  tubercular  disease  itself,  is  still  left  behind,  past  all 
help  from  incision.  So  it  is  also  with  dilatation  of  the 
bronchi  :  it  is  not  a  single  bronchus  that  is  at  fault  ;  in  most 
cases   the  number  of  them   is  very  large,  and  the  surgeon 

'"  Moniteur  Chirurgical,"   St.  Petersburg,  1894. 


APPENDIX    A. 


447 


cannot  lay  them  all  open.  In  both  these  conditions,  when 
the  patient  has  got  over  the  dangers  of  operation — always 
serious  for  those  who  are  broken  in  health — and  when  he 
ought  to  be  enjoying  the  advantages  of  having  his  cavity 
drained,  the  original  disease  still  goes  on,  and  if  incision  has 
not  hastened  death,  it  has  at  most  only  delayed  it.  For  this 
i^eason  the  passion  for  operating  is  now  almost  gone,  and 
there  is  a  daily  increase  in  the  number  of  those  physicians 
who  forbid  the  opening  of  these  cavities,  at  all  events  as 
a  usual  treatment. 

Taiifert,  Bull,  Krecke,  Runeberg,  Park  and  de  Cerenville, 
are  very  clear  on  this  point  ;  the  last  of  them  gives  us  a  list 
of  6  cases  after  operation,  five  of  whom  died,  and  the  sixth 
was  thought  not  likely  to  recover.  Again,  the  operation 
itself  is  not  free  from  danger.  Taiifert  and  Werth  show  that 
of  loo  cases  5  die  directly  from  the  operation,  70  live  only  a 
fortnight  after  it,  and  15  less  than  a  month.  This  leaves 
only  10  to  be  really  the  better  for  the  treatment,  to  say 
nothing  of  any  hope  of  permanent  recovery.  Heemorrhage 
and,  above  all,  pneumothorax,  are  the  commonest  causes  of 
death. 

Since  1885,  the  date  of  Truc's  thesis,  I  have  collected 
8  cases  by  different  surgeons  of  incision  for  tubercular  cavity. 
If  we  were  to  pin  our  faith  on  them  alone,  this  method  would 
seem  to  gave  excellent  results  ;  for  they  give  6  cures,  or 
improvements,  and  only  2  deaths,  one  with  signs  of  gan- 
grene of  the  lung,  and  one  from  sudden  profuse  hjemo- 
ptysis.  But  over  and  above  the  fact  that  they  were  cases 
specially  suited  for  operation,  I  fear  that  surgeons  have 
published  their  successes  rather  than  their  failures.  ^ly 
figures  therefore  do  not  in  the  least  influence  the  opinion 
that  I  have  already  expressed. 

B. — Bronchiectasis. 

Incision  has  not  given  good  results  in  this  disease.  You 
open  a  cavity  full  of  accumulated  secretions,  and  you  feel 
confident  that  as  drainage  goes  on,  and  the  cavity  slowly  gets 
smaller,  your  patient  will  improve  ;  and  then  the  signs  of 
septic  absorption  begin  all  over  again,  because  there  are 
multiple  dilatations  burrowing  elsewhere  in  the  lung.  This 
is  what  happened  in  the  cases  recorded  by  Bull  and  Biss : 
the/<9^/  vi07'tem  examinations  showed  that  beside  the  cavities 
that  had  been  incised  there  were  many  others  of  various 
sizes.      I   have  the   same   story  to   tell   of  a  case   of   my 


448  SURGERY    OF    THE    CHEST. 

own  :  I  resected  a  piece  ot  the  third  rib,  exposed  the  lung, 
and  made  my  way  through  two  inches  of  toughened  lung 
tissue,  and  got  into  a  cavity  large  enough  to  admit  one's  fist, 
and  let  out  an  enormous  quantity  of  unhealthy  pus.  The 
patient  got  over  the  operation,  put  on  flesh  for  a  month,  then 
began  to  waste  again.  As  the  drainage  had  failed  to  bring 
about  the  falling-in  and  cicatrization  of  the  cavity,  I  resected 
the  ribs  over  it.  The  patient  died,  and  the  j!>os^  morievi 
examination  showed  the  presence  of  other  cavities.  Still,  in 
the  course  of  the  last  ten  years  I  find  five  instances  of  opera- 
tion, and  in  every  case  the  patient  was  cured  or  improved  ; 
but  we  must  make  the  same  reservations  here  as  in  cases  of 
tubercular  cavities  :  almost  all  the  cases  have  been  specially 
favourable  for  operation,  and  there  has  been  a  general 
tendency  to  publish  successes,  not  failures. 

Are  we  then  to  forbid  incision  of  the  lung  in  every  case  of 
tubercular  cavity  or  bronchiectasis  ?  No,  but  it  seems  to  me 
that  the  indications  for  operation  are  present  in  only  a  few 
cases ;  and  so  I  get  back  to  the  rules  that  True  laid 
down  ten  years  ago— "When  the  cavity  in  the  lung  is  the 
essential  lesion ;  when  the  symptoms  of  septic  absorption  dom- 
inate the  scene  ;  when  there  is  high  fever,  and  the  patient  is 
shaken  by  cough,  and  exhausted  by  profuse  expectoration, 
then,  without  raising  vain  hopes,  and  simply  to  alleviate  his 
suffering,  we  may  have  recourse  to  incision  of  the  lung. 
Now  and  again  a  marked  improvement  has  been  noted." 

Lavenstel  has  recorded  a  case  where  he  incised  and  drained 
a  cavity  in  the  upper  lobe  of  the  right  lung.  The  patient 
ceased  to  be  feverish,  he  regained  strength,  and  was  able  to 
do  hard  work.  Unhappily  two  years  later  he  died  of  uncon- 
trollable htemorrhafre. 


C. — Hydatid  Cysts. 

With  this  disease  we  begin  the  list  of  those  morbid 
conditions  of  the  lung  for  which  incision  is  really  efficient  : 
it  is  the  ideal  method.  Left  to  itself  the  cyst  may  indeed 
become  obliterated :  there  are  plenty  of  observations  to 
prove  this  ;  but  this  happy  ending  is  purely  a  matter  of 
chance,  and  Neisser's  statistics  tell  that  of  6i  patients  thus 
left  to  themselves,  15  recovered,  and  36  died.  Uavaine  says 
much  the  same  of  the  evils  of  this  expectant  treatment : 
according  to  him  two-thirds  of  the  cases  die.  Hearn  in 
1875  collected  most  of  the  instances  recorded  up  to  that 
date,  and  came  to  the  same  conclusion.     To  hold  one's  hand 


APPENDIX    A.  449 

on  principle,  when  one  is  dealing  with  a  hydatid  of  a  lung,  is 
thus  simply  to  court  death. 

Since  1873  incision  for  this  disease  has  been  done  so 
often,  that  we  can  judge  of  the  value  of  it.  There  are  the 
figures  given  by  Thomas  (5  cases  of  his  own,  and  27  others) ; 
32  cases  with  only  5  deaths,  and  27  cures.  Lopez,  ol 
Lisbon,  brought  the  list  up  to  36  cases,  still  with  only 
15  deaths ;  and  my  own  table  of  more  recent  records  shows 
that  the  proportion  of  successes  has  been  kept  up.  We 
may  admit  that  the  successful  operations  are  more  readily 
published  than  the  unsuccessful,  still  the  immense  value  of 
incision  for  this  disease  is  beyond  the  possibility  of  dispute. 

Indeed,  what  method  could  we  propose  instead  of  it? 
Simple  puncture  is  hardly  more  useful  than  the  expectant 
treatment.  Out  of  16  cases  thus  treated,  collected  by 
Maydl,  11  died,  either  from  purulent  pleurisy,  or  from 
pneumothorax,  or  actually  from  sudden  suffocation,  due 
to  the  cyst  bursting  into  the  bronchi.  In  Thomas'  statis- 
tics the  expectant  treatment  gives  a  mortality  of  54  per 
cent.,  puncture  gives  27,  incision  16  only.  There  is  no  room 
for  doubt  in  this  matter.  We  must  decide  with  Heidenreich, 
Maydl,  Mackenzie,  Peyrot,  Forgue,  and  I  may  say  with 
the  whole  body  of  surgeons,  whose  opinion  is  worth  any 
thing,  that  incision  is  the  only  right  method.  My  own 
statistics  (1885-1895)  give  II  operations,  with  9  cures,  and 
only  2  deaths.  Success  has  not  always  come  at  once,  and  in 
several  of  the  cases  there  has  been  a  tedious  broncho- 
pulmonary fistula.  One  of  the  deaths  was  due  to  suffocation 
from  passage  of  the  daughter  cysts  into  the  bronchi. 

D. — Gangrene  of  the  Lung. 

In  gangrene  of  the  lung,  the  good  done  by  incision  is,  at 
the  lowest  estimate,  as  great  as  in  hydatid  cyst,  and  if  the 
absolute  number  of  successful  operations  is  not  so  large, 
we  must  remember  that  the  disease  itself  is  much  more 
dangerous.  In  cases  left  without  operation,  the  mortality  is 
from  55  to  65  per  cent,  for  hydatid  cyst,  but  75  per  cent,  for 
gangrene,  so  far  as  we  can  judge  from  statistics  ;  and  if 
we  put  together  the  cases  collected  by  Lebert,  Hutchin- 
son, and  Bonome,  we  find  that  of  71  cases  of  gangrene  left 
to  themselves,  54  died. 

And  what  do  we  learn  from  the  record  of  cases  treated  by 
incision.  In  Truc's  thesis  we  find  13  operations  (1879-1884), 
with  7  cures  and  only  6  deaths,  bringing  down  the  mortality 

29 


450  SURGERY    OF    THE    CHEST. 

from  75  to  50  per  cent.  Richerolle's  figures  are  somewhat 
better  even  than  these  :  in  his  thesis  (1892)  he  gives  31 
operations,  with  17  cures  or  improvements  against  14  deaths. 
Finally,  if  we  take  Fabricant's  list,  which  seems  to  me  very 
carefully  worked  out,  we  get  26  operations,  with  16  cures  and 
10  deaths,  a  mortality  below  50  per  cent.  Taiifert,  in  10 
operations,  gives  7  cures,  and  3  deaths. 

Our  results  will  be  still  better  when  we  operate  earlier. 
The  patient  is  admitted  under  the  physician,  and  too  often 
we  vainly  trust  to  nature,  and  to  inefficient  treatment,  and 
forget  the  surgeon,  or  invoke  his  aid  as  a  last  desperate 
resource.  There  are  plenty  of  operations  that  failed  only 
because  they  were  done  too  late.     In  some  of  the  cases  that 

1  have  tabulated,  the  poison  had  time  to  sow  the  seeds  of 
metastatic  abscesses  in  the  viscera  ;  in  others  the  gangrene, 
at  first  circumscribed,  suddenly  becomes  diffuse  ;  in  others, 
the  patient  is  so  enfeebled  that  he  cannot  stand  the  shock  of 
operation.  Most  of  them  might  have  been  saved  by  a  ready 
diagnosis,  and  an  early  appeal  to  surgery. 

The  prognosis  chiefly  depends  on  the  choice  of  the  right 
time  for  the  intervention  of  surgery,  but  not  on  this  alone. 
Women,  who  are  less  often  attacked  by  the  disease,  do  not 
stand  the  operation  so  well  as  men.  Old  people  are  bad  sub- 
jects for  it  ;  and  Fabricant  has  noted  that,  in  cases  already 
exhausted  before  operation,  only  the  young  pull  through 
after  it :  the  results  in  those  who  are  over  40  years  old 
are  bad.' 

Not  every  case  of  gangrene  of  the  lung  is  fit  for  incision, 
and  we  must  start  by  defining  what  can,  and  wliat  can  not, 
be  done  by  the  surgeon.  First,  the  disease  must  be  circum- 
scribed. A  case  of  diffuse  gangrene  is  altogether  beyond 
operation.  Next,  the  gangrenous  cavity  may  be  circum- 
scribed, and  yet  incision  may  not  be  necessary.  When  the 
patch  of  disease  is  small,  and  the  general  condition  of  the 
patient  is  good,  when  there  are  no  signs  of  approaching 
septicaemia,  and  above  all,  when  the  patient  is  young,  the 
surgeon  must  hold  his  hand.  But  under  other  conditions, 
when  the  cavity  is  well  defined,  and  of  large  size,  when  it 

^  In  15  cases  of  incision,  where  he  was  able  to  ascertain  the 
cause  of  the  gangrene,  the  results  were  as  follows :  6  after  acute 
fibrinous  pneumonia,  4  cured ;  4  after  purulent  bronchitis,  2 
cured,  2  relieved  ;  i  after  inflammation  of  mastoid,  cured.     But 

2  from  foreign  body  in  the  air-passages,  and  2  from  bron- 
chiectasis, all  died. 


APPENDIX    A.  451 

cannot  empty  itself,  and  the  putrid  sloughs  are  beginning 
their  poisonous  work,  then  we  must  carefully  ascertain  the 
exact  seat  of  the  disease,  and  operate  without  delay. 

True  lays  down  two  conditions  as  necessary  before  opera- 
tion :  the  site  of  the  disease  must  be  favourable  for  inter- 
ference, and  there  must  be  adhesions  over  it.  Of  course  it 
is  not  a  matter  of  indifference  whether  the  cavity  is  super- 
ficial or  deep,  and  whether  the  pleura  is  shut  off  or  open  ; 
if  the  cavity  lie  just  beneath  the  surface  of  the  lung,  beneath 
dense  adhesions,  we  shall  have  a  very  much  better  chance 
with  it.  But  those  that  lie  deep,  even  if  the  pleura  be  not 
obliterated  by  adhesions,  are  still  not  inaccessible  ;  and 
Krause  of  Altona  has  published  a  case  of  this  kind,  where 
the  operation  was  brilliantly  successful.  It  was  that  of  a 
man,  aged  36,  with  gangrene  of  the  lung  after  pneumonia. 
When  the  pleura  was  reached  by  resection  of  ribs  and 
removal  of  intercostal  muscles,  it  was  found  to  be  non- 
adherent ;  he  therefore  did  the  operation  by  two  separate 
stages,  in  the  way  that  I  will  describe  later. 

I  have  put  together  13  cases  of  gangrene  of  the  lung,  all 
of  them  subsequent  to  Truc's  work  ;  and  they  give  no  less 
than  II  cures  and  only  2  deaths.  One  of  these  was  a 
woman  aged  34,  who,  only  a  fortnight  previously,  had 
undergone  ovariotomy :  she  died  a  fortnight  after  the 
operation  on  the  lung. 

E.— Abscess  of  the  Lung. 

The  value  of  incision  is  as  far  past  doubt  in  this  disease 
as  in  hydatid  cyst  or  gangrene.  We  may  admit  that  re- 
covery without  operation  is  possible.  Apart  from  small 
circumscribed  collections  of  pus,  overlooked  by  the  surgeon, 
and  absorbed  by  nature,  a  larger  cavity  of  a  regular  outline, 
without  diverticula,  may  empty  itself  through  a  large  opening 
into  the  air-passages,  and  thus  be  healed.  But  huge  anfrac- 
tuous basic  cavities,  ill-drained  along  narrow  tracks  in  the 
lung,  are  far  more  dangerous  things,  as  Frey  has  shown  in 
his  thesis  (Paris,  1891).  Slowly  or  fast  these  patients  go 
down-hill,  and  die  of  septic  absorption,  or  of  sudden  suffo- 
cation from  the  pus  breaking  into  the  bronchi.  Death  is  so 
common,  that  we  dare  not  hesitate,  we  must  operate.  And 
we  find  the  claims  of  incision  for  these  cases  advocated  long 
before  the  time  of  Lister  ;  it  was  done  successfully  ages  ago. 
There  was  Pouteau's  patient  (1753),  the  Abbe  Proton, 
almoner  of  the  great  Hotel-Dieu  of  Lyons :  to  say  nothing 


452  SURGERY    OF    THE    CHEST. 

of  Hippocrates.  But  most  of  these  pioneers  of  surgery  did 
the  operation  without  knowing  it.  The  patient  was  coughing 
and  spitting  pus ;  there  was  a  hot,  red  swelHng  in  the  wall  of 
the  chest ;  the  surgeon  opened  it  as  he  would  have  opened 
a  common  abscess,  and  then  discovered  that  he  had  incised 
a  cavity  of  the  lung.  Later,  when  incision  of  the  chest-wall 
became  generally  practised,  the  operation  was  still  to  some 
extent  a  matter  of  chance  ;  the  incision  into  the  pleura  just 
happened  to  relieve  a  diseased  lung  which  had  already 
infected  the  pleural  cavity. 

Anyhow,  the  operation  for  abscess  of  the  lung  got  through 
its  period  of  probation  in  the  days  before  antiseptic  surgery ; 
thus  it  has  been  less  criticised  than  other  operations  on  the 
lung,  and  its  record  is  a  long  ,one.  I  do  not  give  Truc's 
figures,  because  he  mixes  together  true  abscesses  and  bron- 
chial dilatations,  and  we  know  how  much  worse  the  prognosis 
is  in  these  latter.  Seitz  gives  1 1  cases  of  abscess,  with  8 
cures  or  improvements,  and  3  deaths  ;  Lopez  gives  14,  with 
I  death  ;  RicheroUe  adds  16  cases  to  those  of  Seitz,  giving 
a  total  of  27,  with  19  cures  or  improvements,  and  8  deaths. 
Finally,  we  have  Fabricant's  tables — 38  cases,  with  29  cures 
and  9  deaths  :  and  we  must  remember  that  Taiifert  records 
5  operations,  all  successful. 

Fabricant  made  an  analysis  of  these  cases,  to  find  what 
circumstances  influence  the  result  of  operation  one  way 
or  the  other.  Men  suffer  more  often  than  women,  and 
recover  more  quickly,  and  the  young  fare  better  than  the 
old.  The  nature  of  the  primary  disease  plays  a  great 
part  in  determining  the  course  of  events  :  17  cases  of 
abscess  after  fibrinous  pneumonia  gave  14  cures  and  3 
deaths;  7  after  specific  fevers  gave  the  following  results: 
typhoid,  2  cases,  both  cured  ;  scarlet  fever,  i  case,  which 
died ;  pyaemia,  4  cases,  3  cures,  i  death.  Suppurating 
hydatid  cyst,  3  cases,  all  cured ;  bullet-wound,  2  cases,  both 
cured.  Pneumonia  is  therefore  the  commonest  cause  of 
abscess  of  the  lung,  and  operation  on  abscesses  of  this 
character  is,  in  the  great  majority  of  instances,  crowned  with 
success. 

We  know  that  the  indications  for  any  operation  increase 
as  it  becomes  more  hopeful  and  more  helpful  ;  and  incision 
for  abscess  of  the  lung  is  not  in  itself  dangerous,  and 
gives  excellent  results.  Thus  we  have  become  more  ready 
to  operate  since  Truc's  work  was  published,  and  may  now 
assert  that  wherever  there  is  an  abscess  there  ought  to 
be  an  operation.    No  need  to  wait  till  fever  blazes  up,  till  the 


APPENDIX    A. 


453 


patient  is  threatened  with  septic  absorption,  and  his  general 
condition  is  alarniin,s^ ;  one  has  no  right  to  delay,  save  perhaps 
in  a  case  where  the  abscess  is  very  small,  draining  easily  and 
readily  into  the  air-passages ;  or  where  there  are  multiple 
abscesses,  recjuiring  for  their  evacuation  such  mangling  of 
the  chest  as  would  not  be  justified.  Happily  these  latter 
cases  are  rare. 

'  There  is  one  indication  against  operation,'  says  True, 
'  which  holds  good  absolutely,  and  in  every  case,  and  that 
is  the  absence  of  adhesions  over  the  abscess  :  it  is  rare 
not  to  find  them,  but  they  may  be  absent  if  the  suppu- 
ration is  rapid,  or  in  the  depths  of  the  lung.  If  they  are 
absent,  your  incision  would  bring  about  a  frightful  pyo- 
pneumothorax.' I  have  to  say  of  this  what  I  said  of  incising 
gangrenous  cavities  :  an  abscess  may  lie  deep  in  the  lung, 
the  two  layers  of  the  pleura  may  glide  freely  one  over  the 
other,  and  yet  it  may  be  your  duty  to  incise  the  lung,  taking 
certain  precautions — probably  the  best  thing  is  to  do  the 
operation  by  two  distinct  stages.  I  do  not  admit  the  abso- 
lute authority  of  Truc's  rule,  though  it  is  supported  by  some 
very  eminent  surgeons. 

My  figures  for  the  last  ten  years  (1885- 1895)  give  23 
operations,  with  20  cures  and  3  deaths.  Of  these  3  deaths, 
one  was  from  a  huge  cavity  of  the  whole  of  the  base  of  the 
lung;  the  second  was  from  septicaemia  two  months  after 
operation  ;    the   third   was   also  from  septic  absorption. 

I  must  just  mention  some  other  conditions  of  the  lung 
that  may  come  in  need  of  the  surgeon.  We  need  hardly 
stop  to  consider  foreign  bodies  in  the  lung,  which  have 
entered  it  through  the  chest-wall,  or  from  the  upper  air- 
passages.  Either  they  become  encysted,  and  there  is  nothing 
to  be  gained  by  operation,  or  they  cause  suppuration  in 
the  lung,  and  then  come  into  a  group  of  cases  already 
described.  Fowler's  patient,  with  a  loose  tooth  in  his  air- 
passages,  has  become  a  classical  case.  I  have  given 
Moorhof's  case  in  my  tables — penetrating  gun-shot  wound 
of  the  chest,  fragments  of  rib  carried  in  with  the  bullet, 
suppuration,  incision  of  lung,  death. 

RicheroUe,  in  his  thesis,  gives  a  special  chapter  to  actino- 
mycosis ;  but  this  disease  is  so  very  rare  in  France  that  I 
need  not  delay  over  it.  Either  it  is  so  widely  diffused  that 
no  operation  is  possible,  or  it  is  circumscribed,  and  then  its 
treatment  is  the  same  as  that  of  abscess.  I  know  no 
instance  of  operation  for  this  disease  of  the  lung. 

Hernia  of  the  lung  from  injury  I  have  already  considered; 


454  SURGERY    OF    THE    CHEST. 

the  '  spontaneous '  form  of  this  displacement  may  need 
operation,  if  the  welling  has  a  tendency  to  grow  larger,  and 
causes  distress,  and  prevents  the  patient  from  working. 
Thus,  in  Tuffier's  case,  the  hernia,  long  inactive,  became 
so  troublesome  and  so  painful  on  exertion,  that  the  man 
could  not  follow  his  trade.  Tufifier  made  an  incision, 
exposing  the  swelling,  and  reduced  it  ;  he  then  cut  away 
the  pleural  sac,  and  refreshed  and  sutured  the  ring.  Three 
months  later,  there  was  no  sign  of  relapse. 

Finally,  we  must  note  Guermonprez's  curious  case,  where 
he  resected  pieces  of  six  ribs  to  get  at  a  broncho-pulmonar)' 
fistula,  an  inch  and  a  half  long,  and  sutured  it  with  catgut  : 
the  patient  slowly  made  a  complete  recovery. 

IV. 

The  rules  of  surgical  technique,  says  True,  need  never 
trouble  the  surgeon;  and  he  is  quite  right.  I  shall  not  des- 
cribe the  various  methods  practicable  against  hsemorrhage 
in  wounds,  resections  and  incisions  of  the  lung  ;  and  as  for 
the  wounds  and  the  resections,  what  is  there  to  say  ?  The 
surgeon  is  taking  his  chance  of  what  he  will  find,  and  his 
procedure  will  be  according  to  the  exigencies  of  the  case.  I 
will  only  say  that  if  he  has  to  deal  with  a  wound  of  the  lung, 
he  must  make  his  opening  into  the  chest-wall  very  free,  or 
he  will  never  find  the  bleeding  vessels.  Uelorme's  'temporary 
resection  '  does  this  for  us,  but  such  heroic  treatment  is 
full  of  danger  when  the  patient  is  wounded,  feeble,  and 
drained  of  blood.  And  the  surgeon  will  have  to  steer  be- 
tween Scylla  and  Charybdis,  neither  to  be  too  sparing  with 
his  incisions,  lest  he  fail  to  find  the  source  of  the  haemor- 
rhage, nor  to  cut  too  freely  lest  the  patient  come  in  danger 
of  death  from  shock.  In  the  same  way,  there  are  no  definite 
rules  of  procedure  for  the  removal  of  a  portion  of  the  lung. 
What  is  there  in  common  between  Tuffier's  delicate 
manoeuvres  in  resection  of  the  apex  for  tubercular  phthisis, 
and  the  removal  of  a  mass  of  lung  tissue  protruding  through 
a  wound  of  the  chest-wall,  or  the  eradication  of  a  track  of 
malignant  disease  extending  from  the  chest-wall  to  the  lung  ? 
The  surgeon  must  do  the  best  that  he  can,  suiting  his  methods 
to  his  patient's  needs.  But  incision  of  the  lung  may  now  be 
reduced  to  certain  definite  rules  of  procedure.  The  skin- 
incision  may  be  U,  or  H,  or  T-shaped  as  the  surgeon  prefers 
it ;  anyhow  it  must  give  unhindered  access  to  the  ribs.  You 
must  have  plenty  of  room,  a  right  of  way  to  the  cavity,  and 


APPENDIX    A.  455 

an  opening  into  it  large  enough  to  let  you  cleanse  it  quickly 
and  thoroughly.  What  is  more,  it  might  easily  fail  to  close 
if  the  chest-wall,  after  resection,  did  not  allow  the  gap  to 
become  obliterated  by  apposition  of  its  walls.  You  really  do 
a  sort  of  Estlander's  operation  to  ensure  this. 

Again,  as  Krause  has  pointed  out,  you  must  be  able  to  have 
a  good  look  at  the  pleura,  to  see  if  it  is,  or  is  not,  adherent. 
This  matter  is  so  important  that  the  absence  of  adhesions 
has  long  been  held  absolutely  to  forbid  incision  of  the  lung. 
It  is  certain  that  if  the  cavity  of  the  pleura  is  unclosed,  the 
septic  contents  of  the  lung  cavity,  set  free  by  incision,  may 
find  their  way  into  it,  and  start  a  fatal  pyo-pneumothorax. 
Therefore,  to  know  if  adhesions  are  present,  we  must 
follow  Krause's  plan,  make  a  sufficient  resection  of  several 
ribs,  remove  the  intercostal  muscles,  and  expose  the  pleura 
without  opening  it.  If  it  is  thin,  soft,  and  transparent,  and 
if  one  sees  through  it  the  lung,  rising  and  falling  in  respira- 
tion, then  the  two  layers  are  not  adherent,  the  pleural  cavity 
is  not  obliterated  ;  but  if  it  is  thick,  tough,  and  whitish,  pro- 
bably it  is  adherent,  and  we  can  assure  ourselves  on  this 
point  by  thrusting  a  needle  into  the  lung.  If  the  needle 
remains  steady,  not  oscillating  with  the  movements  of  res- 
piration, then  we  may  proceed  ;  there  is  no  pleural  cavity, 
no  fear  of  pneumothorax. 

In  those  cases,  happily  exceptional,  where  the  cavity  in  the 
lung  has  not,  by  inflammation,  brought  about  this  coalescence 
of  the  layers  of  the  pleura,  must  we  give  up  the  hope  of 
incising  the  lung  ?  True  says  pretty  plainly  that  we  must, 
but  I  have  already  quoted  Krause's  case,  where  operation  was 
successful  in  spite  of  this  difficulty.  Several  ways  of  meeting 
it  have  been  proposed.  The  safest  is  operation  in  two  stages, 
as  Volckmann  proposes  for  hydatid  cyst  of  the  liver.  Having 
reached  the  pleura  you  open  it,  very  carefully,  for  fear  of  the 
lung  collapsing — and  if  it  give  signs  of  collapse  (or  even,  to 
avoid  this,  before  you  open  the  pleura),  you  must  suture  the 
two  layers  together  round  the  area  where  your  pleural  incision 
has  been,  or  will  be  made — then  you  cover  the  pleura  with 
sterilized  iodoform  gauze  and  leave  it  for  5  days  at  least,  if  not 
more.  By  that  time  you  have  adhesions  strong  enough  to  let 
you  open  the  cavity  without  fear  of  infecting  the  pleura. 
This  is  the  best  method,  and  vastly  preferable  to  the  use  of 
caustics. 

But  if  the  patient  is  in  imminent  danger,  and  you  must 
open  the  cavity  at  once,  then  it  is  necessary  to  incise 
the  pleura,  take  hold  of  the  lung,  and  fix  it  in  the  wound, 


456  SURGERY    OF    THE    CHEST. 

uniting  the  two  layers  of  the  pleura  either  by  interrupted 
sutures  set  close  together,  or  by  Roux's  continuous  suture  a 
arriere  point.  I  need  not  go  into  the  details  of  this  method. 
It  is  so  well  known  and  so  often  practised  for  hydaiid  cysts 
of  the  liver,  that  every  surgeon  will  know  how  to  employ  it 
for  incision  of  the  lung.  And  these  central  suppurations  in 
the  lung,  with  no  inflammation  in  their  neighbourhood,  and 
no  alteration  of  the  pleura,  and  no  adhesions,  are  not  so  rare 
as  one  might  suppose.  In  two  of  the  cases  collected  by 
Fabricant,  the  contents  of  the  cavity  made  their  way  between 
the  two  layers  of  the  pleura,  and  set  up  fatal  inflammation  of 
it.  In  two  other  cases  there  was  the  same  absence  of  limiting 
adhesions,  so  that  incision  of  the  cavity  was  followed  in  one 
case  by  empyema,  and  in  another  by  pyo-pneumothorax, 
which  involved  another  operation.  Roux,  to  avoid  these 
disasters,  sutured  the  two  layers  of  the  pleura  together  before 
opening  a  cavity  in  the  apex  of  the  right  lung. 

Once  the  adhesions  are  there,  whether  they  be  the  work  of 
Nature  or  of  Art,  the  next  thing  is  to  open  the  cavity.  You 
once  more  assure  yourself,  by  means  of  an  exploring 
needle,  that  you  are  going  right  for  it ;  you  leave  the  needle 
zn  sM,  and  thus  have  it  to  guide  you  into  the  cavity.  The 
best  way  to  open  it  is  with  Paquelin's  cautery,  just  heated  to 
a  faint  dull  red.  This  seals  the  smallest  vessels  as  it  divides 
them,  and  thus  you  avoid  the  flow  of  blood,  so  dangerous  to 
those  who  are  enfeebled  by  disease.  It  was  this  bleeding 
that  proved  fatal  in  one  of  the  cases  in  Fabricant's  collection, 
and  gave  great  trouble  in  three  others.  You  should  only  use 
the  knife  if  the  layer  of  lung-tissue  over  the  cavity  is  thin 
and  toughened,  and  even  then  it  is  best  not  to  trust  to  it. 

Once  you  have  opened  the  cavity,  you  put  in  your  finger 
and  dilate  the  opening.  If  any  secondary  cavities  open  into 
the  first  one,  you  break  down  the  septa  between  them  with 
your  finger  nail :  but  you  must  only  do  this  with  the  greatest 
caution,  and  must  respect  any  strands  or  bridles  of  tissue 
traversing  the  cavity,  lest  you  tear  open  some  vessel. 

The  exploratory  puncture  often  fails  ;  if  it  does,  is  one 
bound  to  give  up  incision  of  the  lung?  No,  you  must 
still  incise  the  toughened  lung-tissue,  and  even  if  you  fail  to 
find  pus,  your  operation  will  nevertheless  do  good.  The 
cavity,  nearly  but  not  quite  opened,  will  ulcerate  or  break 
through  its  wall  more  easily  at  this  point  of  least  resistance. 
There  are  plenty  of  observations  to  show  this.  M.  Grcmbe's 
case  is  a  remarkable  instance  of  this.  It  was  not  till  five 
days  after  incision  of  the  lung  that  the  dressings,  which 


APPENDIX    A.  457 

had  been  dry  all  this  time,  were  soaked  with  an  enormous 
quantity  of  pus,  and  the  expectoration  was  proportionately 
diminished.  In  James'  case  the  pus  escaped  three  hours 
after  the  operation  ;  in  Krimer's,  two  hours  ;  in  Kunberg's, 
two  days  ;  in  Cayley  and  Gould's,  several  days.  Finally, 
Quincke  gives  a  case  where  he  made  a  way  with  the  cau- 
tery into  the  thickness  of  the  lung,  and  the  pus  did  not  find 
exit  through  this  opening  till  twenty-three  days  later,  during 
a  violent  fit  of  coughing. 

Once  you  have  opened  the  cavity  you  must  drain  it  care- 
fully. You  have  resected  the  rib  freely  enough  to  make  a 
large  opening  in  the  chest-wall,  and  the  fluid  and  fcetid 
debris  will  have  no  difficulty  in  getting  out.  Still,  cases 
have  been  recorded  where  the  surgeon  had  to  make  a 
counter-opening,  and  to  drain  the  lung  right  through.  To 
ensure  good  drainage,  use  a  soft  rubber-tube,  together  with 
strips  of  iodoform  gauze.  This  method  has  stood  trial  well, 
and  most  surgeons  seem  to  have  adopted  it. 

Ought  we  to  irrigate  the  cavity?  No,  emphatically,  not 
even  very  gently.  A  better  plan  is  to  wipe  its  walls  with 
pledgets  of  absorbent  wool,  and  to  do  even  this  cautiously, 
lest  one  should  lay  open  any  vessel.  Fabricant  says  that 
four  of  his  collected  cases  show  definite  bad  results  from 
irrigation.  In  one  of  them  the  use  of  a  lotion  containing 
boric  acid  and  thymol  set  up  fatal  inflammation  of  the  air- 
passages. 

Conclusions. 

1.  The  surgery  of  the  lung  does  not,  as  Gliick  said  it  did, 
follow  that  rule  of  general  surgery  '  Ubi  hsemorrhagia  ibi 
ligatura,  ubi  tumor  ibi  extirpatio,  ubi  pus  ibi  incisio.'  The 
structure  of  the  lung  and  its  air-passages,  the  part  it  plays  in 
sustaining  the  life  of  the  blood,  its  relations  with  the  heart, 
and  the  presence  of  a  pleural  cavity,  all  forbid  great  expecta- 
tions, and  limit  the  power  of  the  surgeon. 

2.  Resection,  incomplete  or  complete,  of  a  pait  of  the 
chest-wall,  to  reach  a  wound  of  the  lung  and  stop  a  mortal 
haemorrhage,  as  a  last  chance,  is  doubtless  an  ultimate 
measure  that  we  must  recognize  as  justifiable;  but  it  is  dan- 
gerous, and  not  yet  sanctioned  by  experience. 

3.  Resection  of  tuberculous  masses  ought  to  be  pro- 
scribed. If  the  disease  be  advanced  or  diffused  the  mutilation 
necessary  for  its  removal  would  be  beyond  the  patient's 
strength.     If  the  infective  nodule  be  circumscribed,  general 


458  SURGERY    OF    THE    CHEST. 

treatment  will  deal  with  it  as  efficiently  as  an  operation,  and 
without  its  risks. 

4.  Resection  of  a  part  of  the  lung  for  primary  malignant 
disease  is  not  even  worth  discussing.  An  accessible,  single, 
circumscribed  growth  would  be  a  clinical  wonder  that  would 
evade  our  present  powers  of  observation.  The  utmost  that 
the  surgeon  can  do  is,  after  the  example  of  Kronlein,  to  lollow 
even  into  the  lung  a  sarcoma  growing  from  the  chest-wall : 
but  this  will  never  be  more  than  one  of  the  brilliant  excep- 
tions of  surgery. 

5.  With  pulmonary  cavities  surgical  intervention  is  more 
precise,  and  more  general.  But  incision  for  tuberculous 
cavities,  and  for  bronchial  dilatations,  will  very  seldom  be 
practised  :  for  these  conditions  are  almost  always  diffuse. 
In  every  such  case  the  operation  is  only  palliative. 

6.  Hydatid  cysts,  on  the  contrary,  and  gangrene,  and 
abscess,  can  be  vastly  improved  by  incision.  This  is  radical 
treatment  in  the  true  sense  of  the  word,  and  many  lives  are 
saved  by  it.  To  speak  too  highly  of  incision  in  these  cases 
is  simply  impossible,  and  the  physicians  who  have  the  care 
of  them  ought  never  to  forget  the  precious  gifts  offered  to 
them  by  surgery. 

7.  The  technique  of  the  removal  of  lung-tissue  varies  so 
widely  with  the  character  of  the  tumour  submitted  to  opera- 
tion that  one  cannot  define  the  rules  of  it.  But  the  details 
of  incision  of  the  lung  have  been  accurately  settled.  Free 
incision  of  the  soft  parts,  adequate  resection  of  the  ribs, 
operation  in  two  stages,  or  thorough  suture  of  the  two  layers 
of  the  pleura,  if  they  be  not  adherent,  opening  into  the  lung 
with  the  cautery  at  dull  red  heat,  no  irrigation,  respectful 
avoidance  of  vessels  whose  rupture  would  cause  hjemorrhage, 
drainage  of  the  cavity  with  soft  rubber  tubes,  and  iodoform 
gauze. 


459 


APPENDIX   B. 

ON    BULAU'S    TREATMENT    OF    EMPYEMA    BY  CON- 
TINUOUS    SYPHON-DRAINAGE. 

I  GIVE  here  Dr.  Bulau's  own  account  of  his  method,  and 
have  added  to  it,  in  the  form  of  a  debate,  abstracts  of  the 
favourable  and  unfavourable  opinions  of  it  that  have  been 
pubhshed'  by  other  surgeons.  The  controversy  is  worth 
reading,  on  account  of  the  way  in  which  it  sets  forth  some  of 
the  practical  difficulties  in  the  treatment  of  empyema. 

'  I  worked  out  this  method  because  I  saw  such  lamen- 
table results  (permanent  contraction  of  the  lung)  follow 
the  admission  of  air  into  the  pleura.  I  reasoned  that,  since 
the  elastic  force  of  retraction  in  the  lung  is  to  the  pressure 
of  the  atmosphere  only  as  i  to  loo,  therefore  a  column  of 
fluid,  30  to  33  inches  high,  would  easily  overcome  it.  That 
a  lung,  after  long  collapse,  can  still  expand  again  if  you 
lessen  the  pressure  of  the  atmosphere  on  it,  I  learned  from 
a  case  of  fistula  of  15  months'  duration,  where  my  method 
was  successful.  You  incise  the  skin,  puncture  the  chest 
with  a  trochar  and  cannula  between  a  fourth  and  a  fifth  of 
an  inch  wide,  slip  a  soft  rubber  catheter  through  the  cannula, 
put  a  clip  on  it,  fix  it  to  the  chest  wall,  connect  it  by  a  piece 
of  glass  tubing  with  a  long  piece  of  rubber  tube  filled  with 
lotion,  and  lower  the  long  tube  into  some  lotion.  If  you 
leave  a  coil  of  the  tube  loose  on  the  bed,  the  patient's  move- 
ments in  bed  will  not  stir  the  catheter.  The  objection  to  my 
method — that  it  leaves  masses  of  fibrin  in  the  chest — is  un- 
reasonable. I  admit  that  the  catheter  often  gets  blocked  at 
first,  but  either  you  can  put  this  right  by  going  down  the 
tube  with  your  finger  and  thumb,  or  you  can  syringe  lime- 
water  up  the  tube,   or  in  a  day  or  two  a  fit   of  coughing  will 

'  For  references,  not  already  given,  see  Bulau,  "  Ztschr.  f.  Klin. 
Med.,"  1891,  xviii.,  31  ;  Slajner,  "  Wien.  Klin.  Wchnschr,"  1891, 
p.  229 ;  Glaser,  "  Resectio  Costarum,"  Hamburg,  i8go,  and 
"  Ztschr.  f.  Klin.  Med.,"  1891,  xviii.,  p.  481. 


46o  SURGERY    OF    THE    CHEST. 

drive  a  lot  of  pus  into  the  tube,  and  set  it  going  again.  If 
the  patient  keeps  feverish,  either  there  is  suppuration  round 
the  puncture,  or  the  tube  is  blocked  ;  you  had  better  wait 
and  see  what  happens  ;  for  if  you  take  out  the  catheter,  you 
can  hardly  ever  get  it  in  again  ;  you  ought  not  to  touch  it 
lor  at  least  eight  days.  The  catheter  does  not  get  nipped 
by  the  ribs,  for  with  my  method  the  chest  does  not  fall  in. 
If  there  is  pain,  the  syphonage  must  be  reduced,  unless  the 
pain  be  due  to  irritation  of  the  pleura  by  the  catheter.  After 
some  time,  you  may  let  the  patient  get  about,  keeping  the 
lower  end  of  the  tube  in  a  bottle  hung  below  his  chest  ; 
later  still,  you  may  cut  off  the  tube,  and  just  keep  the  end  of 
the  catheter  in  place  till  all  is  healed.  There  is  no  need  to 
wash  out  the  pleura.  Even  if  the  pus  be  offensive,  my 
method  will  be  applicable  to  the  case  ;  but  a  gangrenous 
empyema  depends  on  gangrene  of  the  lung,  and  therefore 
resection  is  necessary.' 

Dr.  Imaiermann  (Basel):  'I  consider  that  the  modern 
operations  for  empyema  are  too  severe,  and  that  Dr.  Bulau's 
method  is  the  best  possible  treatment  of  empyema  ;  it  can- 
not set  up  pneumothorax,  and  it  maintains  negative  pressure 
within  the  pleura.  If  the  tube  gets  blocked,  you  can  apply 
suction  to  the  end  of  it,  or  syringe  up  it,  and  so  drive  the 
masses  of  fibrin  back  into  the  pleura  ;  they  will,  in  time, 
break  up  and  be  absorbed.  In  three  or  four  weeks  (ihe 
patient  may  have  been  walking  about  for  some  time  with 
a  portable  apparatus)  you  take  out  the  tube,  if  the  discharge 
has  ceased.  But  of  course  this  method  is  only  valuable  if 
the  lung  can  still  expand.  It  is  not  suited  for  cases  of 
pyo-pneumothorax,  or  advanced  phthisis,  or  very  chronic 
empyema,  or  for  gangrenous  empyema,  though  I  did  cure 
one  case  of  this  kind  with  it.  It  is  excellent  for  large,  simple, 
ordinary,  recent  empyema,  and  for  double  empyema.  In 
cases  following  pneumonia,  there  is  one  drawback,  that  the 
pus  is  often  very  tenacious,  and  the  adhesions  very  extensive.' 

Dr.  Slajner  (Graz)  :  '  I  have  observed  eighteen  cases  of 
empyema  treated  by  this  method,  with  very  good  results. 
That  some  of  the  cases  ended  in  death  from  tubercular  or 
amyloid  disease  is  no  argument  against  it.  In  six  of  my 
cases,  there  was  already  a  fistulous  sinus  ;  all  of  them  were 
cured  ;  and  it  is  certain  that  this  method  can,  in  a  relatively 
short  period,  cure  cases  of  this  kind.  In  three  of  the  six,  the 
ribs  were  so  close  together,  and  the  sinuses  ran  such  a 
tortuous  and  difficult  course,  that  it  was  necessary  to  resect 
a  small  piece  of  rib.' 


APPENDIX    B.  461 

Prof.  Hofmokl  (Vienna)  :  '  I  consider  this  method  both 
inconvenient  and  unnecessary.  Either  the  air  gets  into  the 
pleura  while  the  patient  is  coughing  hard,  and  you  are  try- 
ing to  dislodge  masses  of  fibrin  blocking  the  tube,  or  sooner 
or  later  the  precautions  against  admitting  air  break  down. 
I  have  often  seen  empyema  patients  getting  about  in  great 
discomfort,  believing  the  apparatus  was  air-tight,  when  at 
every  cough  you  could  hear  the  air  whistling  in  and  out  of  the 
pleura  alongside  the  catheter.  A  little  fluid,  now  and  then, 
oozes  into  the  bottle,  to  their  great  satisfaction,  but  most 
of  it  goes  into  the  dressings.  Dr.  Bulau's  method  is  worst 
of  all  in  cases  of  tuberculous  or  gangrenous  empyema.' 

Prof.  Pel  (Amsterdam):  '  I  have  often  tried  this  method, 
but  have  now  given  it  up  altogether  ;  1  had  two  cases  where 
it  succeeded,  and  then  had  a  number  of  failures.  It  does 
not  get  rid  of  the  masses  of  fibrin  ;  it  is  difficult,  if  the  inter- 
costal spaces  are  narrowed  ;  and  it  sometimes  causes  pain 
and  bleeding  inside  the  chest.' 

Prof.  Schede  (Hamburg)  :  '  This  method  is  admirable  in 
theory,  but  not  always  easy  in  practice.  That  it  often  fails,  is 
shown  by  Prof  Glaser,  whose  22  cases  of  resection  and  free 
incision,  with  only  one  death,  and  that  from  amyloid  disease, 
include  5  cases,  where  Dr.  Bulau's  method  had  been  tried 
and  had  failed.  But  it  is  to  be  noted,  in  its  favour,  that  Dr. 
Simmonds  had  8  continuous  successful  cases  with  it  ;  in  the 
ninth  case,  the  tube  continually  became  blocked,  and  a  free 
incision  had  to  be  made.  All  these  nine  cases  were  children. 
It  is  absurd  to  use  this  method  in  cases  of  gangrenous 
empyema.  I  had  one  case  where  it  answered  admirably — a 
woman,  aged  29,  with  a  small  empyema  on  the  left  side  ;  (a 
year  before,  she  had  suffered  total  putrid  pyo-pneumothorax 
of  the  right  side,  cured  by  free  resection  and  incision).  The 
catheter  slipped  out  on  the  third  day  ;  but  the  fluid  did  not 
re-collect,  and  she  healed  rapidly.  And  it  is  a  most  excellent 
method  for  cases  of  double  empyema.  But  the  working  ot 
it  is  easily  thrown  out  of  order  by  blocking  of  the  tube,  or 
by  sudden  movement  of  the  patient  ;  it  is  altogether  too 
elaborate.  Think  what  a  problem  it  presents  ;  you  have  to 
keep  at  rest,  night  and  day,  a  restless,  perhaps  delirious, 
sick  child,  till  everything  is  healed  up,  or  to  watch  incessantly 
a  feverish,  sleepless  patient,  that  no  chance  turn  of  his  body, 
or  pull  on  the  tube,  may  in  a  moment  spoil  all  your  work.' 

Dr.  Glaeser  (Hamburg) :  'There  is  not  a  word  to  be  said 
in  favour  of  this  method.  You  learn  nothing  as  to  the  condi- 
tion of  things  inside  the  chest.     You  have  no  idea  where  the 


462  SURGERY    OF    THE    CHEST. 

end  of  the  catheter  has  gone  ;  instead  of  relieving  the  lung 
at  once,  you  leave  it  still  compressed,  especially  if  your  tube 
gets  squeezed  by  the  dressings.  Out  of  8  cases,  where  I  did 
resection  and  free  incision  after  Dr.  Bulau's  method  had 
failed,  in  one  the  pus  was  foetid,  in  two  the  catheter  was  taken 
out  and  could  not  be  put  back,  in  three  it  was  always  getting 
blocked,  in  two  rigors  and  fever  occurred  in  spite  of  it.  Dr. 
Bulau's  method  is  tedious,  dangerous,  and  useless.  You  can 
never  get  a  mass  of  fibrin  through  a  long  narrow  tube,  and 
why  should  we  leave  these  masses  as  hot-beds  of  infection 
inside  the  chest?  In  Schede's  first  series,  of  12  cases,  four  had 
large  masses  of  fibrin  ;  in  my  21  cases,  five  had  large  masses 
(one  of  them  was  of  enormous  size)  to  say  nothing  of  smaller 
ones.     Even  if  the  method  does  succeed,  it  is  terribly  slow.' 

The  weight  of  opinion  seems  to  me  against  this  method, 
and  I  do  not  think  it  has  been  received  with  much  favour  in 
England. 


4^3 


INDEX. 


PAGE 

Abscess,  extrapleural    . .     35 

—  subphrenic       . .  . .   422 

—  or  bronchiectasis,  oper- 
ation for  . .       298,  300 

—  of  lung  . .  . .  . .   285 

Fabricant  on  . .   452 

—  Frey  on  . .   451 

—  Pouteau  on  •  •   451 

Reclus  on  . .   451 

—  —  —  Richerolle  on  . .   452 

Seitz  on  . .   452 

Accidents,  run-over         . .       8 
Acland,   on  operation   for 

arrest  of  haemoptysis   . .   324 
Actinomycosis       . .  . .   416 

—  effusion  in         . .  . .    197 

—  history  of         . .  . .   417 
Acute   oedema  after   mal- 
ignant disease  . .  . .  407 

Adhesions  in  phthisis      . .   319 

—  presence  or  absence  of  298 

—  preventing  pneumotho- 
rax . .  . .  ■  •     74 

—  production  of  . .  . .   299 
Air-passages,  foreign  bodies 

in  the      . .  . .  . .   356 

AUbutt,    on    puncture    of 
chest        . .  . .  . .    187 

Ambroise  Pare,   influence 

of 185 

Amyloid  disease  and  em- 
pyema    . .  . .  . .   249 

Angelo,  on  hernia  of  lung     80 
Anaesthetic    in    operation 
for  empyema     . .  . .   232 

Anterior  mediastinal  sup- 
puration . .  . .  . .    163 


Anterior  mediastinum,  in- 
flammation of   . .        154,  163 

Apex  beat  in  pericardial 
effusion   . .  . .  . .   388 

Arteries,  intercostal, 
wounds  of 

Artery,  internal  mam- 
mary, course  of 

Aspergillus,  in  diseased 
lung-tissue 

Aspiration  of  the  heart, 
Senn's  experiments  on 

—  —  hydatid  cysts,  dan- 
gers of    . . 

—  in  malignant  disease  . . 
subphrenic  abscess, 

danger  of 
Andral,  on  gangrene  after 
pneumonia 


87 


414 

377 

412 
406 

428 


303 


Bacteriology  of  empy- 
ema        . .         . .         . .   207 

Ballance,  on  mediastinal 
suppuration        . .  . .    i65 

Bamberger,  on  haemo- 
ptysis      ..         _. .  ..43 

Barety,  on  bronchial  glands  338 

Barling,  on  subphrenic 
abscess    . .  . .  . .   424 

Barlow  and  Wilks,  on 
subphrenic  abscess    422,  435 

Bartels,  on  abscess,  extra- 
pleural    . .  . .  . .     36 

Bastian,  on  emphysema   ..     55 

Bayard  Holmes,  on  empy- 
ema . .  . .  . .   209 


464 


INDEX. 


PAGE      ! 

Beck,  on  wounds  of  lung  113 
Beez,  on  bronchial  glands 

341.  348 

Begbie,  on  oedema  in 
empyema  . .  . .   223 

Bell,  on  fractures  of  costal 
cartilages  . .  . .     23 

Bell  (J.),  on  wound  of  the 
heart       . .         . .  . .   372 

Bergmann  (von),  on  foreign 
bodies  in  lung  . .  . .    120 

Biedert,  on  bronchial 
g'ands     . .  . .  . .   342 

Billroth  and  Menzel,  on 
caries  of  ribs     . .  . .   154 

—  on  pleurisy  after  frac- 
ture, 36 ;  tuberculous 
caries      . .  . .  . .    159 

Biondi,  experiments  on 
resection  of  lung  . .   327 

Block,  experiments  on  re- 
section of  lung,  327,  on 
woundsof  heart  123,372,373 

Boegehold,  experiments 
on  chylothorax. .  ..   202 

Boerhaave,  on  hernia  of 
the  lung. .         . .  •  •     79 

Borck,  on  malignant  dis- 
ease        . .  . .  . .   402 

Bouchard,  on  septic 
pleurisy  . .  . .  . .   208 

Bouchut,  on  empyema, 
2o5,  on  incision  of  tuber- 
cular cavity        . .  . .   314 

Bouveret,  on  convulsions 
from  irrigation,  261 ;  on 
haemorrhage  from  empy- 
ema cavity  . .       258,  259 

Boyce,  on  aspergillus      . .   415 

Boyer,  on  abscess,  extra- 
pleural, 35 ;  on  emphy- 
sema, 57 ;  on  hernia  of 
lung         . .  . .  . .     84 

Bramann,  on  emphysema     55 

Breath  gymnastics  after 
empyema  . .  . .   274 

Brinton,  on  sternum,  usual 
displacement      . .  . .     27 


PAGE 

Bristowe,  on  aspiration  of 
hydatid  cysts     . .  . .    413 

Broadbent,  on  malignant 
disease     . .  . .  . .   406 

Bronchial  glands,  position 
of  . .  . .  . .   337 

•  some  diseases  of    . .   336 

Bronchi,  incision  of,  pro- 
posals for  . .  •  •   3  -^6 

Bronchiectasis       . .  . .   286 

— ■  Reclus,  on        . .  . .   447 

Brunei's  case,  foreign  body 
in  bronchus       . .  . .   367 

Bryant  (J.),  on  surgical 
anatomy  of  posterior 
mediastinum      . .  . .   354 

Bulau's  method  of  syphon- 
drainage  . .       231,  459 

Bull,  on  incision  of  tuber- 
cular cavity        . .  . .   333 

Butlin  and  Colby,  on 
malignant  disease         . .   402 

Callender,  on  needle- 
wound  of  heart. .  ..   133 

Campe,  on  tumours  of  ribs 
and  sternum       . .  . .    170 

Cancer  of  breast,  simulat- 
ing disease  of  rib  . .   167 

Cappelen,  case  of  suture 
of  wound  of  heart         . .   382 

Caries  of  ribs         . .  . .    154 

—  in     empyema- 

wound     . .  . .  . .   253 

sternum      154,  163,  165 

—  after  typhoid   . .  . .    156 

Carless,  on  caries  after 
typhoid   . .  . .  . .    156 

Caro,  operation  for  second- 
ary malignant  disease 
of  ribs 181 

Casper,  on  wounds  of 
heart        124 

Castlenau  and  Ducrest, 
experiments  on  wounds 
of  heart 123 

Causes  of  diaphragmatic 
hernia      . .  . .  . .    144 


INDEX. 


465 


Causes  preventing  healing 
of  empyema 

Cayley,  on  convulsions 
from  irrigation,  261 ; 
haemoptysis  in  wounds 
of  lung,  no;  operation 
for  arrest  of  haemopty- 
sis 

Cerebral  abscess  and  chest 
disease     . . 

—  embolism  in  wounds 
of  heart  . . 

Cervical  ribs 
Champney's    experiments 

on  emphysema  . . 
Chaussier,  on  hernia  of  the 

lung         ..  .. 

Chest,   concussion  of    the 

—  congenital  malforma- 
tions 

Chest-wall,  foreign  bodies 

working  out  through     . . 
Children      and      run-over 

accidents 
Chloroform -syncope, 

heart-puncture  in 
Choreic  movements    after 

operation  for  empyema 
Chronic  empyema 

—  inflammation  of  bron- 
chial glands 

Church,  on  lever  in  malig- 
nant disease 

Churton,  on  haemor- 
rhagic  effusions 

Chylothorax 

—  treatment  of    . . 
Clarus,  on  displacement  of 

ensilorm  process 

Claye  Shaw,  on  fractures 
of  ribs  in  the  insane 

Collapse,  power  of  re- 
covery of  lung  from 

Comby,  on  pulsating  em- 
pyema 

Complications  in  fractures 
of  ribs 

Concussion  of  the  chest . . 


274 


323 

249 

137 

4 

61 

79 
10 

4 
66 

9 

374 

2  30 
270 

340 

403 

198 
200 
203 

34 

18 

277 

224 

15 


Congenital  diaphragmatic 
hernia   . .  . .  143, 

—  malformations  of  chest 

—  —  —  lungs 
Contusion  of  the  chest     . . 
Cooper  (Sir  A.),  on  empy- 
ema 

Corwin,  on  heart  puncture 

Costal  cartilages,  fractures 

of 

—  —  protrusion  of 
Coupland,   on   subphrenic 

abscess    . . 

Couvy,  on  hernia   of  lung 

Croft,  on  removal  of  col- 
lapsed lung 

Cruveilhier,  on  congenital 
malformation  of  lungs  . . 

Curvature  of  spine  after 
emp3'ema 

Cysts,  hydatid 


144 
4 


206 
376 


J  24 
'85 

2S0 


272 
398 


Dalton,  on  diaphragmatic 
hernia      . .  . .  . .    14S 

Dana,   on    heart-puncture  376 

Danger  of  aspiration,  412; 
in  subphrenic  abscess  . .   428 

Davaine,  on  hydatid  cysts     410 

De  Bligny  . .  . .  . .    330 

Deformity  after  Schede's' 
operation  . .  . .    2S0 

Delageniere,  on  gangrene 
of  lung,  311;  suture  of 
lung         320 

Delepine,  on  actinomy- 
cosis       ..  ..  ..418 

Delorme,  on  operation  in 
wounds  of  lung,  117, 
119;  incision  of  tubercu- 
lar cavity  . .  •  •    333 

Demme,  on  bronchial 
glands     . .  . .  . .    34S 

De  Mussy,  on  bronchial 
glands 337 

Dermoid  cysts  of  lung  or 
mediastinum      . .  . .   407 

Desault,  on  wounds  of 
intercostal  artery  . .      92 

30 


466 


INDEX. 


PAGE 

Diagnosis      of     diaplirag- 
matic  hernia      . .  . .    145 

—  —  fracture  of  ribs      . .     20 

hernia  of  lung         83,  84 

"hidden     hydatid" 

of  Hver    . .         . .         . .  439 

tumours  of  ribs  and 

sternum  . .  . .  . .    182 

wounds  of  internal 

mamm&ry   artery         . .     98 

heart  . .   128 

—  lung  108,  114 

Diaphragm,  wounds  of  . .    140 
Diaphragmatic  hernia     . .    140 

simulating      hernia 

of  lung,     or    combined 
with  it     . .  ; .  . .     83 
simulating  pneumo- 
thorax    . .          . .         50,  148 

Dickinson,   on  incision  of 
pericardium       . .  . .   395 

Digital      exploration      of 
empyema  . .  . .   235 

Dilatation  of   left    auricle 

pressing  on  bronchus  . .   350 
Discharge  persistent  after 
operation      for      empy- 
ema . .  . .  . .   254 

Dislocations  of  the  ribs   . .     24 
Displacement  of  sternum       26 
Double  empyema. .  ..   239 

Douglas  Powell,  on  hyda- 
tid of  liver  ..  ..  437 

Drainage  of  empyema     . .   236 

—  tube,  troubles  from     . .   264 
Dressing    after    operation 

for  empyema     . .  . .   236 

Drinkwater,   on    gangrene 
of  lung     ..  ..  ..   311 

Drouin,  influence  of         . .    185 
Drury,     on     paracentesis 
pericardii  . .  . .   394 

Duckworth,  on  aspiration 

of  hydatid  cysts  ..   414 
Dulac,  on   wounds    of  in- 
tercostal artery   . .         88,  89 
Dupuytren,  on  empyema     206 
wounds  of  heart    . .   123 


PAGE 

E  B  E  R  T  H '  s     bacillus     in 

pleural  eilusions  . .   209 

Ecchymosis  in  hsemotho- 

rax  . .  . .  . .    100 

Eddison  on  operation  for 

empyema  . .  . .   247 

Effusions,     186 ;     haemor- 

rhagic      . .  . .  . .   198 

—  in  malignant  disease        404 

—  mistaken    for    new 
growths  . .  . .  . .   398 

— •  pericardial        . .  , .  384 

apex  beat  in  . .  388 

signs  of       . .  . .  386 

—  in  tubercular  phthisis, 

195,  199 
Eisenschitz    on    bronchial 

glands 347 

Embolism,     gangrene    of 

lung  from  . .  . .   303 

Emphysema  . .  . .      55 

—  after  fracture  . .  48,  50 

—  after  surgical  puncture     59 

—  Litten  on  . .  . .   62 

—  of  neck    with  diseased 
bronchial  glands  . .   349 

—  occurring  during  labour     61 

—  resistance  of  tissues  to       60 

—  Riedinger  on    . .  . .     62 

—  treatment  of    . .  . .     62 

—  without  pneumothorax     61 
Empyema  . .  . .  . .   204 

—  and  amyloid  disease        249 

—  after     penetrating 
wound     ..  ..  ..   213 

treatment   . .  . .   246 

—  bacteriology  of  . .   207 

—  breaking  into  lung      . .   225 

—  breath  gymnastics  after  274 

—  causes  of  . .  . .   220 
preventing  healing  of  274 

—  cavity,      haemorrhage 
from        . .  . .       258,  264 

packing  of  . .  . .   255 

—  —  tube  lost  in  . .   265 

—  choreic         movements 
after  operation  for        . .   260 

—  chronic  . .  . .   270 


INDEX. 


467 


Empyema,  curvature  of 
spine  after  . .  . .  272 

—  discharge  persistent 
after  operation  for        . .   254 

—  double  . .  . .  . .   239 

—  drainage  of      . .  . .   236 

—  evacuation  of  . .  . .  235 

—  fistula  after   operation 

for  270 

—  gangrenous      . .       246,  252 

—  general  character  of        210 

—  without  treatment      . .   222 

—  left  worse  than  right . .   212 

—  method  of  healing  of 
after  operation  . .  . .   270 

—  migrations  of  . .  . .   226 

—  necessitatis       . .  . .   222 

—  oedema  in         . .  . .   223 

—  operation  for  . .  . .   230 

—  and  organic  disease    . .   250 
poisonous  lotions       257 

—  period  of  healing  of 
after  operation  . .  . .   270 

—  repeated  puncture   of    230 

—  resection  in      . .  . .   233 

—  retention  of  fibrin 
after  operation  for        . .    255 

—  shock  after  operation  for  246 

—  time      of      leaving      out 
tube,  after  operation  for  272 

—  wasting  of  muscles  in      260 

—  wound,  exuberant 
callus  in  . .  . .  . .   254 

—  —  excoriation  of        . .   252 

—  use  of  iodoform  in  255,  258 
Enlarged      bronchial 

glands,  signs  of  . .   345 

Ensiform     process,     frac- 
ture and  displacement         33 
Erichsen   on  haemoptysis, 
40 ;     on    hernia   of  the 
lung         ..  ._.  ..79 

Estlander's  operation      . .   275 
Evans  on  hydatid  cyst  of 
heart        . .  . .  . .   409 

Ewald  on  power  of  re- 
covery of  lung  from 
collapse  . .  . .  . .   277 


PAGE 

Ewart  on  pericardial  effu- 
sion . .  . .       387,  396 

treatment  of  pneu- 
mothorax . .  . .     68 

Exploratory  puncture  of 
empyema  ..  ..231 

in  malignant  disease  404 

Farier  and  Sabatier  on 
foreign  bodies  in  the 
bronchi  . .  . .  . .  359 

Fever,  with  intrathoracic 
malignant  disease         ..  402 

Fibrin,  frequency  of 
masses  of  . .  . .   234 

Fischer  on  cervical  ribs 
5 ;  heart  puncture  376 ; 
wounds  of  heart  121, 
127;  wounds  of  lung  ..   113 

Fischl  on  bronchial  glands    346 

Fistula  after  operation  for 
empyema  . .  . .   270 

Foltanek  on  incision  with- 
out resection     . .  . .    234 

Fowler  (J.  K.),  on  foreign 
body  in  bronchus,  370  ; 
on  operation  for  arrest 
of  hsemoptysis  . .  . .   324 

Foreign  bodies  in  the  air- 
passages  356 

—  —  Godlee  on  67,  369 
Good  on      . .  . .     67 

—  —  in  heart       ..  ..   136 

—  —  —  lung       . .  . .    120 
—  Reclus  on  . .    453 

—  — working  out  through 
chest-wall  . .  . .     66 

Forlanini  on  production  of 

pneumothorax  . .  . .    325 

Fracture,  pleurisy  after  ..     36 

—  pneumonia  after         . .     43 

—  and  displacement  of 
ensiform  process  . .      33 

—  emphysema  after         48,  50 

—  hernia  of  lung  after    . .     51 

—  injuries  of  heart  in     . .     51 

—  pneumothorax  after   . .     49 

—  thrombosis  after         . .     48 


468 


INDEX. 


I'ACE 

Fracture  of  ribs  . .  . .  14 
diagnosis  of  . .  20 

—  •  —  —  in  the  insane  ..  17 
—  spontaneous  . .  16 

—  —  — •  treatment  of    . .  21 

—  with  internal  injuries   ,  35 

—  of  costal  cartilages     ..  21 

—  —  sternum  . .  . .  25 
Franckel,  experiments  on 

intrapulmonary  injec- 
tion . .  . .  . .   315 

Friintzel  on  malignant 
disease  398,  404  ;  pneu- 
•  mothorax  70,  76  ;  punc- 
ture of  chest  186  ; 
tuberculous  caries  160; 
wounds  of  intercostal 
artery      . .  . .  . .     89 

Fraser  on  haemoptysis  in 
wounds  of  lung  ..    iii 

Frey  on  wounds  of  dia- 
phragm  . .  . .       141,  147 

Freylau  on  aspergillus  196,  415 

Fiirbringer  on  aspergillus     416 

Gangrene  of  lung  . .   302 

from  embolism     303 

— Fabricant  on   . .   450 

Krause  on        ..   451 

—  —  — •  operation  for   . .   307 

—  —  —  Reclus  on         . .    449 

Richerolle  on  . .   450 

Gangrenous  empyema  246,  252 

—  inflammation  of  bron- 
chial glands       . .  . .   337 

Gee  on  noisy  respiration  347 
General     condition     after 

operation  for  empyema  246 
Gerhardt    on  puncture  of 

chest        . .  . .  . .    187 

Gimbert  on  empyema  . .  206 
Glands,  bronchial,  chronic 

inflammation  of  . .   340 

—  —  gangrenous  in- 
flammation of    . .  . .   337 

position  of  . .  . .    337 

signs  of  enlarged        345 

some  diseases  of  . .   336 


PAGE 

Glands,  bronchial,  tuber- 
culous disease    . .  . .   344 

Glaser  on  Bulau's  method     461 

Gliick,  experiments  in  re- 
section of  lung  . .  . .   326 

Godlee  on  foreign  bodies 
in  the  lung  67  ;  pneumo- 
thorax 76 ;  foreign  bodies 
in  the  bronchi  369  ;  der- 
moid cyst  of  lung         ..   407 

Good  on  foreign  bodies   . .     67 

Goodhart  on  vaso-motor 
troubles  after  irrigation  261 

Grimm  on  flagellate  pro- 
tozoa       . .  . .  . .    196 

Gross,  on  suppuration  in 
posterior  mediastinum 
355  ;  foreign  body  in 
bronchus  . .  . .   368 

Griiber  on  cervical  ribs  . .       5 

Gudden  on  fractures  of 
ribs  in  the  insane  . .      17 

Guthrie  on  hernia  of  lung       85 

Gurlt  on  emphysema  56  ; 
fractures  of  costal  cartil- 
ages 22 ;  ribs,  sponta- 
neous fractures  of  16 ; 
fractures  of  the  sternum 
25  ;  on  usual  displace- 
ment of  sternum  30 ; 
pleurisy  after  fracture 
36;  venesection  in  pneu- 
monia after  fracture     . .      45 

Guermonprez,  operation 
for  suture  of  lung         . .   320 

Habershon  on  pneumo- 
thorax in  phthisis         . .     66 

Haemoptysis  after  frac- 
ture . .  . .  . .     40 

—  Bamberger  on  . .     43 

—  in  hydatid  cyst  . .   410 

—  intra-pulmonary  injec- 
tions for  arrest  of  . .   325 

—  operation  lor  arrest  of  323 

—  venesection    for    arrest 

of 325 

—  in  wounds  of  lung      . .    109 


INDEX. 


469 


PAGE 

Haemorrhage,  external,  in 
wounds  of  lung  . .    113 

—  from  empyema-cavity 

258,  264 

—  from  lung  after  aspira- 
tion   251 

—  in  gangrene  of  lung  ..  313 
Hasmorrhagic  effusions  . .  igS 
Hsemothorax       . .  87,  99 

—  alter  fracture. .      41,  47,  48 

—  pleural  effusions  after     103 

—  treatment  . .  . .  104 
Hall    (de    Havilland),    on 

puncture  of  chest         . .    186 

Harris  and  Beale  on 
phthisis  . .  . .       317,  319 

Harris  (Vincent),  on  ma- 
lignant disease  . .  . .   405 

Hastings  and  Storks  on 
incision  of  tubercular 
cavity 332 

Hawkins  (H.),  on  abscess 
of  lung  - .        296,  298 

Hearder  on  fractures  of 
ribs  in  the  insane         . .      17 

Hearn  on  hydatid  cysts        410 

Heart,  accidental  punc- 
ture of 379 

—  aspiration  of,  Senn's 
experiments  on. .  ..    377 

—  cerebral  embolism  in 
wounds  of  . .  . .    137 

—  diagnosisof  wounds  of     128 

—  entry  of  air  into  . .   377 

—  foreign  bodies  in         . .    136 

—  hydatid  cysts  of  . .   409 

—  injuries  of  in  fracture        51 

—  prognosis  of  wounds  of  136 

—  surgery  of  the  . .    371 

—  treatment  of  wounds  of 

138,  382 

—  venesection  in  wounds 

of 138 

—  withdrawal  of  blood 
from  the  . .  . .   378 

—  wounds  of        . .        121,  3S2 

—  —  —  in  paracentesis 
pericardii  . .  . .   393 


PAGE 

Heart-puncture  in  chloro- 
form-syncope    . .          . .  374 

and     heart  -  suture, 

proposals  for     . .          . .  372 

Heidenhain  on  heart,  in- 
juries of  in  fracture     . .  54 

Hennen  on  emphysema 
55,  58  ;    haemoptysis  in 

wounds  of  lung. .          ..  no 

Hermetical       sealing      in 

wounds  of  lung. .          ..  116 

Hernia,  diaphragmatic   . .  140 

—  of  lung  . .          . .          . .  78 

—  —  —  after  fracture   ..  51 
—  Angelo  on         . .  80 

—  —  —  beneath  scar    . .  80 

—  —  —  conditions  of    . .  82 

—  —  —  Demons  on       . .  445 
— •  diagnosis          . .  83 

—  —  —  prognosis          . .  84 
Tuffier  on         . .  454 

—  ' Tulpius  on       . .  80 

Heubner      on      bronchial 

glands     . .  . .  • •    346 

Heusser  on  actinomycosis     418 

Heydenreich  on  aspira- 
tion of  hydatid  cysts     . .    414 

Heydweiller  on  hernia  of 
lung  85  ;  on  gangrene 
of  lung  306 ;  on  aspira- 
tion of  hydatid  cysts    . .   412 

Kingston  on  foreign  body 
in  bronchus        . .  . .    366 

Hippocrates,  influence  of 
185  ;  operation  for  em- 
pyema    . .  . .  . .   204 

Hird  on  haemothorax  after 
fracture  . .  . .  . .      42 

History  of  American  War 
on  emphysema  . .  . .      55 

hsemo- 

ptysisin  wounds  of  lung  in 

—  —  — hernia   of 

lung         ..  ..  81,82 

— pneumo- 
thorax    . .  . .  . .     72 

—  wounds 

of  heart  . .  . .  . .    124 


470 


INDEX. 


History  of  American  War 
on  wounds  of  intercostal 
artery      . .  . .  . .     92 

wounds 

of     internal    mammary 
artery      . .         . .         •  •     94 

operations   for  em- 

205 
285 


pyema     . . 
on  the  luns 


paracentesis      peri- 
cardii     . .  . .  . .   384 

treatment  of    pleu- 
ral effusions       . .       184,  185 

wounds  of  heart    . .   121 

Hofmokl  on  Bulau's 
method  461 ;  on  curva- 
ture of  spine  after  em- 
pyema 273 ;  on  empyema 
necessitatis  225  ;  on  gan- 
grene of  lung  306,  311  ; 
on  hsemorrhagic  effu- 
sions 198 ;  on  incision 
without  resection  234 ; 
on  iodoform  258  ;  on 
operation  for  empyema 
248 ;  on  puncture  of 
empyema  231 ;  on  sub- 
phrenic abscess  426 ;  on 
tubercular  disease  250 ; 
on  tuberculous  caries 
160 ;  statistics  of  opera- 
tions on  lung  . .  . .  298 
Hiiber  on  malignant  dis- 
ease of  lung  . .  . .  400 
Huss    on    gangrene   after 

pneumonia         . .  . .   303 

Hydatid  of  liver,  escape  of 
bile  after  operation      . .   436 

— invading    the 

chest       . .         . .         . .  422 

sternum      . .  . .   167 

lung 398 

—  haemoptysis  in . .  410 

mortality  from      411 

dangers    of    as- 
piration of  ..  ..   412 

heart  . .  . .   409 

—  cysts,  Reclus  on  . .  448 


PAGB 

Hydatid     cysts,     rupture 
of  . .         . .  . .  . .   411 

Hydrothorax         . .  . .    195 

Immermann  on  Bulau's 
method    . .  . .  . .   460 

Incision  and  drainage  of 
pericardium       . .  . .   395 

—  of   bronchi,    proposals 

for  356 

tubercular  cavity       330 

Infection  of  pleura  during 
operation  . .  . .   213 

Inflammation  of  anterior 
mediastinum       . .      154,  163 

Injections  into  lung  in 
tubercular  phthisis      . .   315 

Injuries  of  heart  in  frac- 
ture . .  . .  •  •     51 

—  internal,   fracture  with     35 
Insane,   fractures   of    ribs 

in  the      . .  ..  . .     17 

Instruments  for  explor- 
ing  lung 299 

Intercostal  artery,  wounds 
of  87 

treatment  of  wounds 

of  . .  . ,  . .     9-2 

wounded  in  opera- 
tion for  empyema        . .     88 

Internal  injuries  in  the 
chest        . .  . .  . .      12 

—  —  in  simple  fracture       35 
after   fracture  unfit 

for  operation     . .  . .     46 

Intra-pulmonary  injection, 
deaths  from       ..  ..317 

for  arrest  of  haemo- 
ptysis      . .  . .  . .   325 

Intra- thoracic  malignant 
disease,  fever  with       . .   402 

—  new  growths    . .  . .   398 

—  pulsation  . .  . .   224 
Irrigation,     syncope    and 

convulsions  from  . .   260 

—  troubles  from  . .  . .    259 

—  vaso-motor  and  ther- 
mal troubles  from         . .   260 


INDEX. 


471 


PAGE 

Israel  on  actinomycosis 
417 ;  pleurisy  after  frac- 
ture        . .  . .  .  •     36 

JoNNESco  on  wounds  of 
lung         ..  ..  ..119 

Jung,  experiments  on 
wounds  of  heart  . .   213 

Karplus  on  cerebral  em- 
bolism in  wounds  of 
heart        . .  . .  . .    137 

Kassowitz  on  bronchial 
glands 347 

Kaufmann  on  run-over 
accidents  . .  . .       8 

Keen  on  caries  after  ty- 
phoid      . .  . .  . .   156 

Kidd  on  bronchial  glands 
348 ;  experiments  on  as- 
pergillus  415 ;  on  peri- 
cardial effusion  . .   390 

Kinloch  on  heart-punc- 
ture . .  . .  . .   376 

Kirchner  and  Keen  on 
chylothorax       . .  . .  202 

Knaggs  on  hydatid  cyst 
of  heart  . .  . .  . .   409 

Koch  and  Konig,  experi- 
ments on  intra-pulmon- 
ary  injections    . .  . .   315 

Kochler  on  surgery  of  the 
lung         288 

Kolisko  on  bronchial 
glands     . .  . .  . .   342 

Konig  on  empyema  221 ; 
experiments  on  emphy- 
sema 60;  operation  for 
empyema  . .  . .   247 

Kovacs  on  sudden  oedema 
of  lung 193 

Kronlein,  operation  for 
resection  of  lung  . .  328 

Laceration  of  intercostal 
artery  in  fracture  . .     37 

internal    mammary 

artery  in  fracture  ..      38 


Laceration  of  lung  in  frac- 
ture        . .  . .  . .     38 

pleura  in  fracture        37 

Lacher  on  wounds  of  dia- 
phragm . .  . .  . .    142 

Laennec,  influence  of      , .   184 
Lampe      on      subphrenic 
abscess    . .  . .  . .  425 

Landmarks  . .  . .       i 

Larrey  on  emphysema  58, 

59;  wounds  of  heart  ..   123 
Lawson   Tait  on   hsemor- 

rhagic  effusions  . .    199 

Lees  on  noisy  respiration  347 
Left-sidedness   of  wounds 
of  diaphragm     . .  . .   143 

Le  Fort  on  caries  of  ster- 
num        . .  . .  . .    166 

Lehmann  on  hydatid  cysts  41 1 
Lepine    on    paresis    after 
empyema  . .  . .    260 

Leudet  on  empyema       ..   221 
Lilly  on  empyema  . .   206 

Litten  on  emphysema  62, 

flagellate  protozoa        . .    196 
Lister,  influence  of, 

184, 206,  440 
Liver,  hydatid  of,  invading 
the  chest  . .  . .    422 

Llobet  on  wounds  of  dia- 
phragm  . .  . .  . .   141 

Lockwood  on  caries  after 
typhoid  . .  . .  . .   156 

Lonsdale   on  fractures  of 

the  sternum       ..  ••25 

Lopez  on  hydatid  cysts  . .   412 
Lowson,  operation  for  re- 
section of  lung  . .  . .   328 

Loy  seau  on  hernia  of  lung       84 
Lucas   Championniere  on 
operation  in  wounds  of 

lung         119 

Lung,  abscess  of    286,  451-452 

—  Beck  on  wounds  of    . .   113 

—  dermoid  cysts  of         . .  407 

—  diagnosis  of  wounds  of 

108,  144 

—  empyema  breaking  into  225 


472 


INDEX 


PAGE 

I..ung,  external  haemor- 
rhage in  wounds  of       . .    113 

—  Fischer  on  wounds  of        13 

—  foreign  bodies  in  . .  120 
— •  gangrene  of  the  302,  449-451 
—  from  embohsm      303 

—  haemorrhage  from 
after  aspiration  . .  ..251 

—  hermetical  seahng  in 
wounds  of  . .  . .    116 

—  hernia  of  . .  . .     78 

—  history  of  operations  on  2S6 
— •  injections  into  in  tuber- 
cular phthisis     . .  ■  •   315 

—  instruments  for  explor- 
ing _ 299 

—  laceration    of,    in  frac- 

ture   . .  . .  . .     38 

—  operation  for  gangrene, 
apparent  failure  . .   312 

—  operation  in  wounds  of, 

112,  117 

—  phthisical,  suture  of 
opening  in  . .  . .   320 

—  posture  in  wounds  of       116 

—  power  of  recovery  of 
from  collapse     . .  . .   277 

—  Reclus  on  malignant 
disease  of  . .         . .   444 

wounds  of  the       444 

—  resection  of  apex  of    . .   326 

—  treatment  of  wounds  of    114 

—  True  on  surgery  of  the  288 
- —  use  of  probe  in  wounds 

of  . .  . .  . .    114 

—  wounds  of  . ,  . .  106 
—  McCormac  on       113 

—  congenital  malforma- 
tion . .  . .  . .       2 

—  surgical  anatomy        . .       2 

Mackenzie  and  Abbott 
on  subphrenic  abscess     430 

Macnamara  on  fractures 
of  ribs  in  the  insane     . .      19 

Madelung  on  hydatid  cj^sts  410 

Maisonneuve  on  sternum, 
usual  displacement       . .     27 


PAGE 

Malgaigne  on  fractures  of 

ribs,  spontaneous  . .      16 

Malignant  disease  . .   398 

—  —  acute   oedema  after 
aspiration  for     . .  . .   407 

—  —  aspiration  in  . .   406 
effusion  in  . .  . .   404 

—  —  exploratory      punc- 
ture in     . .  . .  . .   404 

—  —  signs  of       . .  . .   405 

—  —  value  of  oxygen  in 

400,  407 

—  —  expectoration  of 
fragments  in      . .  . .   400 

—  —  —  —  Reclus  on   . .   444 
sputa  in      . .   402 

—  —  —  of  pericardium      397 
Malle       on      paracentesis 

pericardii  . .  . .   385 

Mammary      arteries, 

wounds  of  . .  87,  93 

]\Iarchant,     operation    for 

suture  of  lung    . .  . .    320 

Marcus,    experiments    on 

resection  of  lung  . .   326 

Marjolin   on  laceration  of 

lung  in  fracture  . .      39 

Marks       on      mediastinal 

suppuration        . .  . .    164 

Maydl    on    hydatid    cysts 

40S,    412 ;      hydatid     of 

liver  436,  439 ;  subphre- 
nic abscess  423,  426,  432 
McCormac  on  wounds   of 

lung         , 113 

McDonnell    on  laceration 

of  lung  in  fracture  . .  39 
McGillivray    on     hydatid 

cysts         . .  . .  . .    408 

Meacham  on  caries    after 

typhoid   . .  . .  . .    157 

Mediastinal  dermoid  cyst, 

pulsation  of       . .  , .   407 

Medico -legal     aspect      of 

wounds  of  heart         124,  125 

— lung       . .    106 

Meltzer      on     subphrenic 

abscess  . .  . .     434 


INDEX. 


473 


Merklen,  operation  for 
pyo-pneumothorax       . .    323 

Messner  on  elasticity  of  ribs 
26;  on  tuberculous  caries  159 

Method  of  healing  of  em- 
pyema after  operation      270 

Michaux  on  incision  of 
tubercular  cavity,  333  ; 
operation  in  wounds  of 
lung       ..  ..  117.  "9 

Migrations  of  empyema        226 

Moffet  on  incision  of  tu- 
bercular cavity..  ..   330 

Monneret  and  Fleury  on 
pneumothorax   . .  ■  •      71 

Moore  on  putrid  empyema    226  ■ 

Morel-Lavallee  on  hernia 
of  the  lung         ..  78.  S4 

Morison  (A.),  on  abscess 
of  lung  . .  . .        296,  301 

on  incision  of  pleu- 
ral effusion         . .  . .    189 

Moutard-Martin  on  em- 
pyema 221  ;  onhaemor- 
rhagic  effusions  199,  404 

Mliller,  operation   for   tu- 
mour  of   ribs    169  ;     on 
.  pulsating  empyema      . .   224 

Muscles,  wasting  of  in 
empyema  . .  . .   260 

Myrtle  on  subphrenic  ab- 
scess       . .  . .  . .   427 

Necrosis  of  ribs  . .         ..   154 

—  —  sternum      . .  . .    154 

Needle  wounds  of  heart  . .    132 
Neisser  on  hydatid  cysts 

408,  410 
N^laton  on  diaphragmatic 
hernia     148 ;     pneumo- 
thorax     . .  . .  • •     74 

Nelaton  (Ch.),  on  wounds 
of  lung    . .  . .  . .    120 

Neudorfer  on  emphysema       58 
Netter  on  effusion  in  tu- 
bercular phthisis          . .    195 
Neveux,      on     bronchial 
glands 337 


New  growths,  intrathor- 
acic   398 

—  —  mistaken  for  effu- 
sions       . .  . .  . •   399 

Nicaise  on  caries  of  ster- 
num          166 

Nothnagel  on  cough  of 
pleurisy  . .  . .  • .    I95 

Nussbaum  on  diaphrag- 
matic hernia      . .  . .   148 

CEdema  in  empyema       . .   223 

—  sudden  of  lung  after 
aspiration  . .  . .    189 

CEsophagus,  Zenker  on 
diverticula  of     . .  . .   341 

Ogle  on  pericardial  effu- 
sion . .  . .  . .   390 

Omboni  on  operation  in 
wounds  of  lung  ..117 

Operation  for  abscess  or 
bronchiectasis    . .       298,  300 

arrest      of     hsemo- 

ptysis 323 

—  —  cervical  rib  . .       6 
diaphragmatic 

hernia      . .  . .  . •    147 

empyema  . .  . .   230 

gangrene,  apparent 

failure  of  . .  . .    312 

subphrenic    abscess  428 

tumours  of  ribs  and 

sternum  . .          . .          ._.    183 
paracentesis    peri- 
cardii        393 

wounds  of  lung  112,  117 

—  —  on  sternum  165,  166 
Organic   disease  and   em- 
pyema    . .          . .  . .   250 

Ormerod,  on  fractures  of 
ribs  in  the  insane  ..      18 

Osteo-sarccma  of  lung, 
secondary  . .  . .   399 

Oxygen,  value  of,  in  mal- 
ignant disease  . .       400,  407 

Packing  of  empyema- 
cavity     . .  . .  .  •   255 


474 


INDEX. 


PAGE 

Pagenstecher,  experiments 

on  hsemothorax  . .    loi 

Paget    (Sir  J.),  on   caries 

after  typhoid     . .  . .    156 

Paracentesis       pericardii, 
history  of  . .  . .    384 

risk  of  anaesthesia  in  394 

Parasitic     organisms      in 

pleural  effusions  . .    196 

Partsch,  on  actinomycosis  417 

Pean,   on  tumour  of  lung  168 

Pel,     on     absorption      of 

empyema,  208;   Bulau's 

method    . .  . .  . .   461 

Penrose  and   Lee  Dickin- 
son, on  subphrenic  ab- 
scess       . .         . .         . .  425 

Penzoldt,      on     intra  pul- 
monary injections         ..   316 
Pepper,   results   of    intra- 

pulmonary  injection     ..   318 
Pericardial  effusions        . .   384 

apex  beat  in  . .   388 

signs  of       . .  . .   386 

Pericardium,  incision  and 
drainage  of        . .  . .   395 

—  malignant     disease    of  397 
Period    of  healing  of  em- 
pyema   after    operation  270 

Perry,  on  haemorrhage  in 

gangrene  of  lung  ..   313 

Pheraeus      . .  . .  . .   330 

Phthisis,  adhesions  in      . .   319 

—  hypodermic       medica- 
tion of     . .  ..  . .   317 

—  tubercular        . .  . .    314 
Pierre   Marie,  on  congen- 
ital malformations        . .       4 

Pilling,  on  cervical  ribs   . .       5 
Pitt,  on  bronchial  glands     346 
Pitt    (Newton),    on    bron- 
chial glands       . .  . .   337 
Pitts,     on    hernia   of    the    • 
lung,  78;  run-over  acci- 
dents       . .          . .  . ,       8 
Pleura,  haemorrhage   into 

100,  112 

—  laceration  of ,  in  fracture     37 


PAGE 

Pleurae,  landmarks  of      . .  2 
Pleural      effusions      after 

haemothorax      . .         , .  103 
ordinary  acute      . .  186 

—  —  other  than  empy- 
ema        . .         • .         . .  184 

—  —  secondary  . ,  . .   194 

after  fracture         . .     36 

Pneumonia  after  fracture    43 

—  venesection  in,  after 
fracture  . .  . .  •  •     44 

Pneumothorax      . .          . .  64 

—  adhesions      preventing  74 

—  after  fracture  . .          •  •  49 

—  in   the   American    war  72 

—  conditions  of  . .          . .  73 

—  Ewart,  on  treatment  of  t8 

—  from  exploratory  punc- 
ture         . .          . .          . .  69 

—  Frantzel,  on    . .  70,  76 

—  Godlee,  on       . .         . .  76 

—  Nelaton,  on      . .          •  •  74 

—  in  phthisis        . .          . .  64 

—  Saussier,  on     . .          . .  71 

—  treatment  of    . .           68,  77 

—  in  typhoid  fever          . ,  65 

—  West,  on           . .          . .  67 

—  without   emphysema..     61 
Poisier  and  Jonnesco,   on 

incision  of  tubercular 
cavity 333 

Poisonous  lotions  and  em- 
pyema    . .  . .  . .  257 

Poland,  on  dislocations  of 
the  ribs,  24;  fractures 
of  ribs,  15,  44 ;  hernia 
of  lung,  85  ;  venesection 
in  pneumonia  after  frac- 
ture        . .         . .         • •     45 

Poore,    on    actinomycosis  419 

Porter,  on  abscess  of  lung  295 

Postempski,  on  diaphrag- 
matic hernia      ..  ..151 

Posterior  mediastinum,  in- 
flammation of    . .  . .   336 

Posture  after  operation  for 
empyema  . .  . .   237 

—  in  wounds  of  lung      . .    116 


INDEX. 


475 


PAGE 

Power  of  recovery  of  lung 
from  collapse     . .  . .  277 

Pr  ce,  on  hydatid  cyst  of 
heart       . .  . .  . .   409 

Probe,  misuse  of,  in  wounds 
of  heart  . .  . .  . .   127 

—  use  of,  in  wounds  of 
lung         ..  ..  ..114 

Prognosis  of  diaphragmatic 
hernia      . .  . .  . .    146 

hernia  of  the  lung     84 

wounds  of  heart    ..    136 

Pulmonary      apoplexy, 

SimpsDn  on       . .  . .  444 

Pulsating  empyema  . .  223 
Pulsation,  intrathoracic  224 
Puncture  of  empyema     ..  231 

—  —  pleural  effusion, 
without     aspiration     . .    188 

Purple,  on  wounds  of  heart  128 
Pye  Srnith,  on  venesection  46 
Pyaemia    after     operation 

for  empyema     . .  . .   248 

Pyo-pneumothorax,  oper- 
ation for  . .  . .  318 

QuENU  and  Hartmann, 
on  surgical  anatomy  of 
posterior  mediastinum. .   352 

—  on  operations  in  wounds 

of  lung    ..  ..  ..112 

Rapid  respiration  in  run- 
over  accidents   . .  . .       9 

Raynaud  and  Vallin,  on 
convulsions  from  irriga- 
tion . .  . .  . .   261 

Reclus,  on  gangrene  of 
lung,  306;  hernia  of  the 
lung,  78 :  surgery  of  the 
lung         . .  . .       288,  443 

Repeated  puncture  of 
empyema  . .  . .   230 

Resection  of  apex  of  lung 

326,  445 

—  of  rib  not  always  neces- 
sary in  empyema  . .   234 


Rest,  necessity  of,  in 
wounds  of  heart  ..    125 

in     wounds      of 

lung         . .  . .  . .   106 

Retention  of  fibrin  after 
operation  for  empyema 

255,  462 

Ribs,  caries  of      . .  •  •   154 

—  cervical  . .  . .       4 

—  dislocations  of  the     . .     24 

—  elasticity  of      . .  . .     26 

—  fractures  of      . .  . .     14 

—  necrosis  of        ..  ..154 

—  tumours  of       . ,  . .    167 
Richardiere,  operation  for 

pyo-pneumothorax       . .   323 

Richerand,  operation  for 
tumour  of  ribs  . .  . .    180 

Richerolle,  on  actinomy- 
cosis, 419;  hydatid  cysts  411 

Riedinger,  on  the  chest, 
10;  dislocations  of  the 
ribs,  24;  emphysema,  62; 
fractures  of  costal  cartil- 
ages, 23 ;  needle  wounds 
of  heart,  135;  tubercu- 
lous caries,  158;  wounds 
of  intercostal  artery,  93 ; 
wounds  of  lung  ..    iig 

Risks  of  anaesthesia  in 
paracentesis     pericardii     39 

puncture  of  pleural 

effusion   . ,  . .  . .   189 

Rivington,  on  sternum, 
usual  displacement        27,  29 

Roberts,  on  withdrawal 
of  blood  trom  heart,  379 ; 
wounds  of  the  heart     . .   372 

Rolandus,  on  hernia  of 
lung         85 

Rolleston,  on  bronchial 
glands     . .  . .  . .   341 

Romero,  on  paracentesis 
pericardii  . .  . .  385 

Rose,  on  injuries  of  heart 
in  fracture,  52  ;  rest  in 
wounds  of  lung,  107; 
wounds  of  heart  . .    130 


476 


INDEX. 


Rosenbach,  on  incision 
without  resection  . .    234 

Roser,  on  healing  of  empy- 
ema . .  . .  . .    270 

Rossier,  on  haemorrhagic 
efiiisions  . .  . .    198 

Rotcli,  on  paracentesis 
pericardii  . .  . .   393 

Roux  (P.  J.),  experiments 
on  pneumothorax         . .     72 

Roux,  suture  a  arriere- 
point        . .  . .  . .    308 

Rudall,  on  hydatid  of 
liver         435 

Ruggi,  operation  for  re- 
section of  lung  . .  . .   328 

Rumpf,  on  mediastinal 
new  growths      . .  . .   407 

Run-over  accidents  . .       8 

Rushmore,  on  foreign  body 
in  bronchus         . .       356,  363 

Rydygier,  on  diaphrag- 
matic hernia      . .  . .    152 


168 
71 


391 


Sarcoma  of  sternum,  pul- 
sating 

Saussier,  on  pneumothorax 

Savory  (Sir  W.),  on  para- 
centesis pericardii 

Schede,  cases  of  empyema, 
213,  214238;  on  Bulau's 
method,  461 ;  expansion 
of  lung  after  empyema, 
271 ;  tubercular  disease, 
251;  operation,  277 ;  op- 
eration, deformity  after, 
280  ;  operation  for 
secondary  malignant  dis- 
ease of  ribs 

Schlange,  on  actinomy- 
cosis 

Schmidt,  experiments  on 
resection  of  lung 

Schuller,  on  syphilitic 
caries  of  sternum 

Secondary  pleural  effusions  194 

Secondary  scirrhus,  pleu- 
ral effusion  in    . .  . .    198 


iSo 


419 


327 


155 


PAGE 

Seifert,  on  dilatation  of 
the  bronchi        ..  ..350 

Seitz,  on  bronchial  glands  345 

Senn's  experiments  on 
aspiration  of  the  heart  377 

Septicasmia  after  opera- 
tion for  empyema         . .   248 

Settegast,  on  empyema 
necessitatis,  225 ;  frac- 
tures of  ribs,  15,  43  ; 
tuberculous  caries        . .    159 

Severeano,  on  diaphrag- 
matic hernia       . .  . .    149 

Sharkey,  on  suppuration 
in  posterior  mediastinum  355 

Shaw  (L.),  on  bronchi- 
ectasis    . .  . .  . .   355 

Sheild,  on  acute  necrosis 
of  sternum,  162;  on 
paracentesis     pericardii  385 

Shock  after  operation  for 
empyema  ..  ..   246 

Site  of  incision  in  empyema  233 

puncture  of  pleural 

effusion   . .  . .  . .    189 

Skielderup,  on  paracentesis 
pericardii  . .  . .   385 

Slajner,  on  Bulau's 
method,  460;  power  of 
recovery  of  lung  from 
collapse  . .  . .  . .    277 

Sloan,  on  accidental 
puncture  of  heart         . .   3S1 

Smith  (A.  H.),  experi- 
ments on  pneumothorax     76 

Smith  (T.)  &  Cheadle,  on 
foreign  body  in  bronchus 

362,  365 

Solly,  on  venesection  in 
pneumonia  after  fracture    46 

Sonnenburg,  on  incision 
of  tubercular  cavity     . .   333 

Spine,  curvature  of,  after 
empyema  . .  . .   272 

Stewart  (Sir  G.),  on  para- 
centesis pericardii         . .   391 

Steavenson,  on  paracen- 
tesis pericardii  . .  . .    393 


INDEX. 


477 


Stelzner,    on    needle- 
wounds  of  heart  . .    134 
Sternum,  caries  of  154,  163,  165 
— :  fractures  of       . .  . .      25 

—  tumours  of       . .  . .    167 

—  .usual  displacement  . .  26 
Stokes,  on   pulsating  em- 

P3^ema     . .  . .  . .   224 

Strange,    on    gangrene   of 

lung  310       — 

Strangulated   diaphrag- 
matic hernia      ..       146,151 
Subphrenic  abscess  ..   422 

causes  of     423,  425,  431 

history  of  . .  . .   422 

—  —  operation  for  . .   428 

—  —  presence    of   gas  in  424 

—  —  secondary  to  th^r- 
acic  disease        , .  . .  432 

—  —  signs  of  . .  . .  424 
Succussio  Hippocratis  . .  197 
Sudden  cedema  of  lung  . .  191 
Suppuration  round  empy- 

ema-wound         . .  . .    252 

"Surgery    of    the   heart"  371 

lung,   Reclus  on  454 

Sutton  (Bland),  en  dia- 
phragmatic hernia,  144; 
on  aspergillus    . .  . .    415 

Suture     ot     opening      in 

phthisical  lung  . .  •  •   320 

Syncope     after     puncture 

190,  42S 

—  and  convulsions  from 
irrigation  . .  . .    260 

Syphilitic  caries  of  ribs 
or  sternum  . .  •  •    I55 


Terrillon,     on      sudden 

oedema  of  lung  . .  . .    191 

Thomas,  on  aspiration  of 

hydatid    cysts  . .  . .     413 

Thrombosis  after  fracture  48 
Tice,  on  bronchial  glands  342 
Tiedemann,   on    bronchial 

glands 341 

Tilmann,  on  cervical  ribs       5 


PAGE 

Tourdes,  on  wounds  of 
internal  mammary  arterj'    95 

Toussaint,  on  operation 
for  arrest  of  haemoptysis  324 

Treatment  of  emphysema     62 

—  —  fractures  of  costal 
cartilages  . .  . .     23 

ha:mothorax  . .    104 

hernia  of  lung  85,  453 

needle-wounds  of 

heart        ..          ..  ..   135 

pneumothorax  68,  77 

—  —  sternum,  usual  dis- 
placement          . .  . .      32 

tuberculous     caries  162 

wounds  of  heart  138,382 

intercostal 

artery      . .  . .  . .      92 

internal  injuries  in 

the  chest  . .  11 
internal    mammary 

artery 

—  —  lung 
Trephining   of   the   rib  in 

empyema 
Troubles    from    drainage- 
tube         

—  —  irrigation    . . 
Trousseau,    on  abscess  of 

lung,    301 ;  on   paracen- 
tesis pericardii  . . 
True  and  Lepine,   experi- 
ments     on      intra-pul- 
monary  injection  ..   315 

—  on  foreign  bod}^  in 
bronchus,  357,  361 ;  on 
gangrene  of  lung,  306; 
incision  of  tubercular 
cavity,  333;  results  of 
intra-pulmonary  injec- 
tion, 318 ;  surgery  of  the 
lung,  288;  surgical  an- 
atomy of  lungs  . .  . .       3 

Trzebicki,  statistics  of 
operations   on   lung     . .    297 

Tube  lost  in  empyema- 
cavity      . .  . .  . .   265 

Tuberculous  caries  . .    )  57 


:.  13 

99 
114 

234 

264 
259 


3S5 


478 


INDEX. 


PAGE 

Tubercular  cavities, 
Lavenstel,  on     . .  . .   448 

Taiifert  and  Werth 

on  447 

incision  of  . .   330 

—  disease  and    empyema  250 

—  phthisis  . .  •  •   314 

Mikon,  on  . .  445 

Reclus,  on  444,  446 

Tuberculous      disease     of 

bronchial  glands  . .   344 

Tuffier,    on  hernia  of  the 
lung,     78;     method     of 
loosing  the  pleura,  308  ; 
operation   for   resection 
of    lung,    329;     pleural 
effusions    after    haemo- 
thorax     . .  . .  . .    104 

Tulpius,  on  hernia  of  lung     80 
Tumours  of  ribs    . .  . .    167 

sternum      . .  . .    167 

Tyson,  on  hydatid  of 
liver         435 

Use  of  curette  for  em- 
pyema    . .         . .  . .   236 

—  —  iodoform  in  em- 
pyema . .  _       . .    _  255,  258 

irrigation  during  op- 
eration for  empyema   . .   236 

Valleix,  on  pain  of 
pleurisy  . .  . .  •  •    195 

Vaso-motor  and  thermal 
troubles  from  irrigation  260 

Velpeau,  on  empyema     . .   206 

Venesection  for  arrest  of 
haemoptysis        . .  . .   325 

—  in  pneumonia  after 
fracture  . .    ■      . .  •  •     44 

—  Pye  Smith,  on  . .     46 

—  in  wounds  of  heart     . .    138 
Virchow,   experiments   on 

wounds  of  heart  . .    123 

Voelcker,  on  bronchial 
glands,  544,  348;  gan- 
grene of  lung     . .  . .   309 


Wagner,  on  packing  of 
empyema  cavity  . .   255 

Walsham,  on  haemothorax 
after  fracture     . .  . .     42 

Walshe,  on  curvature  of 
spine  after  empyema     . .   273 

Washbourn,  on  the  pneu- 
mococcus  . .  . .   186 

Wasting  of  muscles  in 
empyema  . .  . .   260 

Watson  Cheyne,  on  tuber- 
culous abscess,  162;  tub- 
erculous caries  . .    158 

Watson,  experiments  on 
heart-puncture  . .  . .   374 

Weber,  on  wounds  of 
heart        . .  . .  . .   123 

Weeks,  on  foreign  body 
in  bronchus        . .  . .   367 

Weist,  on  foreign  body 
in  bronchus        . .  . .   363 

Westbrook,  on  withdrawal 
of  blood  from  the  heart  378 

West  (C),  on  gangrene 
after  pneumonia  . .   303 

West  (S.),  experiments  on 
pneumothorax,  75 ;  in- 
cision of  serous  effusion, 
188  ;  operation  for  arrest 
of  haemoptysis,  324 ; 
paracentesis  pericardii 
391 ;  pneumothorax,  67; 
venesection  for  arrest  01 
haemoptysis        . .  . .   325 

Wheaton,    on    aspergillus  415 

Wheelhouse,  on  medias- 
tinal suppuration,  164; 
incision  of  tubercular 
cavity,  315;  on  subphre- 
nic abscess        . .  . .   427 

White  and  Wood,  on 
bacteriology  of  empyema  209 

Wiederhofer,  on  bronchial 
glands 347 

Wiglesworth,  on  fractures 
of  ribs  in  the  insane     . .      17 

Willard,  on  foreign  body 
in  bronchus        . .         . .   358 


INDEX. 


479 


PAGE 

Wilson  Fox,  on  gangrene 
after  pneumonia  . .   303 

Wilson,  on  incision  of 
pleural  effusion  ..    189 

Wintrich,  on  haemothorax 

loi,  103 

Wisner,  experiments  on 
absorptive  power  of 
pleura     . .  . .  . .    103 

Wounds  of  diaphragm     . .    140 

heart     ..     121,  371,  382 

in     paracentesis 

pericardii  . .  , .   393 

—  —  intercostal    arteries    87 


Wounds  of  internal  mam- 
mary arteries      . .         87,  93 

lung  . .       106,  444 

— operation  in  112,  117 

— with  wounds  of 

heart       ..  ..  ..    128 

Wright,  on  bronchial 
glands     . .  . .  . .   348 

Zenker,  on  diverticula  of 
oesophagus         . .  •  •   341 

Ziemssen,  on  needle- 
wounds  of  heart  . .   132 


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